5,662 results
Unknown·Toxicity to protonitazene
Four adults died on 24 June 2024 from protonitazene toxicity after ingesting illicitly purchased drugs they believed to be MDMA and cocaine. Protonitazene is a novel synthetic opioid approximately 100 times more potent t…
22y · Male·Gunshot wounds to the torso (Raghe Abdi); Multiple blunt and sharp force injurie…
This inquest examined three deaths: elderly couple Maurice (87) and Zoe Antill (86) who were stabbed to death at their home on 16 December 2020, and Raghe Abdi (22), a radicalised young man on bail being monitored by cou…
89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…
An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…
terminal palliative care in a girl with a clinical diagnosis of aspiration pneum…
A 12-year-old girl with severe cerebral palsy (quadriplegia) died from aspiration pneumonia whilst in state care following removal from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence,…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
40y · Male·septic complications from injuries received from multiple dog bites sustained on…
Colin Amatto, a 40-year-old Yuin man, died from septic complications following a devastating dog attack with over 80 bite wounds. Critical clinical lesson: the same dog (Boof, a Staffordshire Bull Terrier) had attacked a…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
47y · Male·Compression of the neck arising from hanging
47-year-old man with antisocial personality disorder, psychosis, and methamphetamine use died by hanging. He presented to emergency departments on 10, 19, and 20 September 2021 with suicidal ideation, auditory hallucinat…
35y · Male·Neck compression due to hanging
Joshua Gonzalez, 35, died by suicide on 5 September 2020 after being discharged from Footscray Hospital. He had been apprehended by police under section 351 of the Mental Health Act after threatening self-harm and asking…
32y · Female·mixed drug toxicity including phenobarbitone
A 32-year-old woman with borderline personality disorder and depression died by intentional self-administration of pentobarbitone (Lethabarb) accessed from her workplace. She had experienced extensive family violence in …
50y · Female·Hanging
Karla Lee Jordan, a 50-year-old accountant at Ballarat Health Services, died by hanging on 29 August 2019. The coroner found workplace stress from a toxic workplace culture was the primary suicide stressor. Following a r…
41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm
Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…
69y · Male·thoracic aortic aneurysm with dissection
Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…
58y · Male·Drowning
A 58-year-old man drowned while attempting to rescue his son from a rip at an unpatrolled beach. The deceased was not a competent swimmer and was unaware of dangerous sea conditions including strong currents and swell. H…
0y · Male·Unascertained in the setting of a remote head injury
Child A, a six-month-old Aboriginal boy, died from unascertained cause in the setting of a remote head injury sustained during family violence. The father violently assaulted the mother while holding the child unsupporte…
68y · Male·Effects of carbon monoxide
Harold Clayton, 68, died from carbon monoxide poisoning while working in the confined engine bay of his moored boat. The generator was running to supply power for his battery work, producing toxic carbon monoxide levels …
7y · Female·Group A Streptococcus (Streptococcus pyogenes) pneumonia with sepsis
A 7-year-old previously healthy girl died from Group A Streptococcus pneumonia with sepsis after paramedics failed to transport her to hospital despite recording a severely elevated heart rate (172 and 168 bpm) on 15 Sep…
15y · Male·multiple injuries caused by a motor vehicle accident
Kailab Moir, a 15-year-old Aboriginal boy with FASD, complex trauma, and ADHD, died in a single-vehicle rollover while a passenger in a stolen vehicle. He had been in out-of-home care since age 5 with approximately 35 di…
67y · Male·Intracranial haemorrhage complicating coronary artery bypass graft surgery follo…
A 67-year-old man died from intracranial haemorrhage following coronary artery bypass graft surgery. He had suffered a right coronary artery dissection during percutaneous coronary intervention at Sunshine Hospital and w…
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