5,662 results
89y · Male·unascertained - natural causes
Harold Edward Burgess, aged 89, died in Port Phillip Prison's medical unit from unascertained natural causes following a fall on 6 November 2022 that resulted in cervical spine fractures. He was deemed unsuitable for sur…
0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour
Baby W died within 40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision…
28y · Female·unascertained
Lisa Joanne Govan, aged 28, disappeared on 8 October 1999 in Kalgoorlie, Western Australia, last seen standing outside the Club Deroes outlaw motorcycle gang clubhouse at 7:30 am. The coroner established, beyond all reas…
54y · Female·Pulmonary thromboembolism complicating left calf deep venous thrombosis in the s…
54-year-old woman with frontotemporal dementia and Parkinson's disease died from pulmonary thromboembolism complicating deep venous thrombosis. She fell during the night at a disability accommodation facility and was fou…
40y · Female·Stab wounds to the chest and abdomen
A 40-year-old woman was fatally stabbed by her former intimate partner who had an extensive history of family violence offending and multiple breaching intervention orders. Despite multiple service contacts in the days b…
31y · Male·Head injuries - horse rider struck by a motor vehicle
A 31-year-old Japanese horse rider died from head injuries after being struck by a motor vehicle while crossing a public road with horses at dawn. Low light conditions (approximately 6:40 am, still dark) impeded the driv…
57y · Female·Asphyxia - Inhalation of liquefied petroleum gas (LPG)
Mrs R, a 57-year-old woman with bipolar disorder, borderline personality disorder, and depression, died from asphyxia by inhalation of liquefied petroleum gas. On 31 March 2024, family unable to contact her requested a p…
18y · Male·compression of the neck in keeping with hanging
An 18-year-old Aboriginal man died by hanging three days after release from prison on home detention bail. He had been displaying acute psychotic symptoms while in prison custody, placed under camera observation due to s…
59y · Male·Shotgun wound to the head
A 59-year-old man with a work-related shoulder injury developed anxiety and depression, later expressing suicidal ideation during mental health treatment. His general practitioners and psychologist provided appropriate m…
25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…
Emmett Brown, a 25-year-old First Nations man, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvida…
31y · Male·compression of the neck secondary to hanging
Rory Van Geleuken, a 31-year-old with longstanding major depressive disorder, generalised anxiety disorder, autism spectrum disorder, and ADHD, died by hanging. He had received mental health treatment since age 17, inclu…
49y · Male·undetermined
A 49-year-old man with paranoid schizophrenia on clozapine became non-compliant with mental health appointments in July 2021. After threatening clinic staff while acutely psychotic, mental health services and police atte…
2y · Female·sequelae of blunt force head and spinal cord injuries
DB, aged 2 years 9 months, died from blunt force head and spinal cord injuries inflicted by her mother's boyfriend after DCJ closed its case in August 2015. The coroner found DCJ made multiple critical failures: acceptin…
23y · Male·Hypoxic ischaemic encephalopathy due to near-drowning
A 23-year-old Indian citizen drowned at an unpatrolled, hazardous beach on Stradbroke Island after becoming caught in a rip current. He was unable to swim. Despite prompt CPR by lifeguards and paramedics with return of s…
36y · Female·head injury
A 36-year-old woman was killed by a young man with early-onset schizophrenia after a chance encounter. The death resulted from a complex series of missed opportunities in mental healthcare management. Key failures includ…
40y · Male·hypothermia
Nathan Booth, a 40-year-old Aboriginal man with opioid addiction, was reported missing on 2 September 2019 after last being seen on 27 June 2019 when he obtained his methadone dose at Canberra Hospital. His body was foun…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
Unknown·Toxicity to protonitazene
Four people died from protonitazene toxicity on 24 June 2024 after inhaling what they believed was cocaine but which was adulterated with protonitazene, an extremely potent synthetic opioid (100 times more potent than he…
Unknown·Toxicity to protonitazene
Four adults died on 24 June 2024 from protonitazene toxicity after purchasing drugs believed to be MDMA and cocaine in Melbourne. Protonitazene is a novel synthetic opioid 100 times more potent than heroin that has conta…
Toxicity to protonitazene
Four adults died on 24 June 2024 following inhalation of cocaine adulterated with protonitazene, a novel synthetic opioid 100 times more potent than heroin. Michael Hodgkinson purchased drugs believed to be MDMA and coca…
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