2,427 results
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…
Three South Australians died following extended waits on ambulance ramps outside metropolitan hospitals. Anna Panella (76) died from pulmonary thromboembolism; Bernard Skeffington (89) died from aspiration pneumonia afte…
50y · Male·plastic bag asphyxia in the setting of ethanol intoxication and blunt force head…
William Heddergott, 50, died from asphyxiation with head injuries while intoxicated, in circumstances suggesting his mother Erica (who pleaded guilty to murder) perpetrated fatal family violence. Clinical lessons include…
78y · Female·Complications of prolonged immobility and malnutrition in a woman with retroperi…
A 78-year-old woman with schizophrenia, depression, and undiagnosed retroperitoneal lymphoma died from septic shock complicating severe pressure ulcers, malnutrition, and dehydration. She had been immobile on a couch for…
86y · Male·Complications of blunt force trauma in a man with cardiac amyloidosis and athero…
An 86-year-old man with dementia, cardiac amyloidosis and atherosclerotic cardiovascular disease died from complications of blunt force trauma sustained in an assault by his adult son. The deceased had been diagnosed wit…
30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…
Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …
89y · Female·Acute upper airway obstruction by food bolus
An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significant discrepancies between reported actions and actua…
51y · Female·Multiple sharp force injuries to the chest
Lynn Marie Cannon, 51, was murdered by her estranged husband Paul Cannon on 5 December 2022 at his residence. After ending their 25-year marriage characterised by coercive control, she had begun a new relationship. When …
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
32y · Female·Head injuries in a motor vehicle incident
Helena Zoe Broadbent, a 32-year-old pregnant Aboriginal woman, died from severe head injuries sustained when her partner William Wilson drove off in a vehicle while she was partially inside it, causing her to be ejected …
79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…
A 79-year-old woman with severe COPD and heart failure presented with two weeks of nausea and vomiting. She was diagnosed with left ventricular failure (EF 33%) on day 1 of admission. Two cardiologists had key roles: Dr …
8y · Male·prematurity-associated lung and bowel disease
Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associate…
0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…
Baby Sidney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell …
2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection
A two-year-old girl died from complications of severe iron-deficiency anaemia and COVID-19 infection. She had significant feeding difficulties, took almost exclusively milk and yoghurt, and was profoundly anaemic with po…
33y · Male·Heat stroke (environmental exposure) in a man with methylamphetamine effect
Travis Hart, 33, died from heat stroke with methylamphetamine effect after abandoning a vehicle during a police intercept in bushland near Kalgoorlie on 25 December 2022. He became separated from companions and was found…
19y · Male·Hanging
SF, a 19-year-old remand inmate with no prior custodial or mental health history, died by hanging in Goulburn Correctional Centre 18 hours after requesting protective placement due to safety fears. He had expressed depre…
19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …
Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…
35y · Male·Hanging
Brent Reker, a 35-year-old prisoner with extensive history of suicide attempts (including hanging, overdose, and self-harm), died by hanging in Forbes Unit at Ravenhall Corrections Centre on 12 December 2019, approximate…
19y · Female·multiple injuries sustained in a train incident
JVM was a 19-year-old with major depressive disorder, anxiety, and possible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St …
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