2,427 results
39y · Female·Blunt force trauma to the head, on a background of alcohol and cannabis toxicity
Elsie May Robertson, 39, died from blunt force trauma to the head sustained during domestic violence by her partner James Grannigan on 6 March 2013. She had consumed alcohol and cannabis. Police response was delayed appr…
31y · Female·raised intracranial pressure due to ventriculoperitoneal shunt dysfunction (disc…
Emilie Le Coz, aged 31, died from raised intracranial pressure secondary to ventriculoperitoneal shunt disconnection. She presented to hospital in March 2010 with progressive headaches, cognitive changes and behaviour de…
36y · Female·Haemorrhage complicating elective caesarean section (placenta praevia accreta)
Ms. Thi Lu, aged 36, died from massive hemorrhage following caesarean section for placenta praevia with underlying placenta accreta. Although imaging could not definitively exclude accreta preoperatively, high-risk prepa…
54y · Female·Hanging
A 54-year-old woman with a history of puerperal psychosis presented with severe depression and anxiety in early 2011. After two suicide attempts, she was admitted to Austin Health's Acute Psychiatric Unit involuntarily. …
60y · Male·medication overdose
Bruce Andrews, a 60-year-old man with major depression and anxiety, died from medication overdose following relationship breakdown and acute alcohol intoxication. He fell from his porch, called his granddaughter reportin…
No death occurred; inquiry conducted under s 30(3) of Coroners Act into cause an…
On 12 January 2013, a catastrophic bushfire broke out at Wambelong Camp Ground in Warrumbungle National Park, NSW, burning 56,280 hectares (95% of the park), destroying 53 houses and 113 other buildings, and damaging the…
11y · Male·Craniocervical trauma
This coronial finding concerns the death of Luke Geoffrey Batty, age 11, killed by his father Gregory Anderson on 12 February 2014 during a cricket practice. Luke was struck with a cricket bat and stabbed with a knife. T…
26y · Male·Multiple injuries sustained in a motor vehicle incident (driver)
Jason Govan, 26-year-old fitter and turner, was killed in a high-speed head-on collision on the Princes Freeway when the opposing driver, suffering untreated schizophrenia and other mental health conditions, drove the wr…
70y · Male·gastrointestinal haemorrhage in a man with gastric ulcers
David Weiser, 70, presented to an emergency department with melaena and dizziness on 11 November 2012. An advanced trainee in emergency medicine, Dr H., examined him and found a haemoglobin of 92 g/L and elevated urea/cr…
35y · Female·coronary artery dissection
Fiona Selby-Fullgrabe, 35, presented to Wallaroo Hospital with chest pain, arm weakness, and diaphoresis. Ambulance noted elevated troponin (121) and activated the chest pain protocol. However, Dr M. discharged her after…
80y · Female·subdural haematoma due to closed head injury sustained in a fall from bed in hos…
An 80-year-old woman with chronic heart failure admitted to hospital fell from bed and hit her head. Although nursing staff were concerned about a possible head injury, the House Medical Officer incorrectly concluded no …
61y · Male·Complications of cutaneous burns
A 61-year-old man with severe chronic schizophrenia and extensive history of arson, suicide attempts and self-harm was admitted as a voluntary patient to a psychiatric inpatient unit and later made involuntary. Despite c…
Female·Verris Dawn Wright: septic shock due to small bowel ischaemia secondary to small…
Two joint inquests examined failures in recognising clinical deterioration in rural hospital patients. Mrs Wright, 86, presented with abdominal pain and a low temperature (early sepsis), but staff did not escalate when s…
40y · Male·coronary artery atherosclerosis
40-year-old male with hypercholesterolaemia presented to general practice with new-onset central chest pain radiating to neck and arm, plus shortness of breath. The practice nurse obtained an ECG and recorded the radiati…
31y · Male·Hanging
Scott Matthew O'Connor, a 31-year-old male, died by suicide in the Maximum Security Unit of Arthur Gorrie Correctional Centre on 22 January 2013. He had been assessed as high-risk for self-harm and placed on 30-minute ob…
46y · Female·Cardiac arrest of unknown origin
Virginia Brown, a 46-year-old Aboriginal woman, died of cardiac arrest of unknown origin on 31 October 2014 while detained under a Mandatory Residential Treatment (MRT) order at CAAAPU (Central Australian Aboriginal Alco…
59y · Male·idiopathic dilated cardiomyopathy (probably alcohol related)
A 59-year-old Aboriginal man died of idiopathic dilated cardiomyopathy in a Darwin police watch house following arrest for the minor offence of drinking in a designated public place. He had severe, documented cardiac dis…
52y · Female·intracerebral haemorrhage in a lady with underlying cerebrovascular disease and …
A 52-year-old woman underwent right carotid endarterectomy for high-grade stenosis. Post-operatively she developed escalating blood pressure readings (160–220 mmHg), headaches, nausea, agitation, and abnormal behaviour o…
19y · Male·hanging
A 19-year-old male inmate with schizophrenia died by hanging at Long Bay Correctional Centre. Critical failures in mental health care contributed to preventability: despite initial referral in February 2013, he was never…
35y · Male·Unascertained, following autopsy. Likely drowning but circumstances undetermined…
A 35-year-old man with chronic alcohol dependence was admitted to the ED with acute alcohol withdrawal and auditory hallucinations. Despite presenting with objective signs of withdrawal (tremor, elevated BP, tachycardia,…
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