3,425 results
26y · Female·Multiple stab wounds
ZSQ, a 26-year-old woman, was fatally stabbed by her intimate partner MJD in April 2020 after a relationship marked by escalating family violence. Critical clinical and systemic lessons include: (1) Recognition of intima…
54y · Female·choking on a food bolus in a woman with an intellectual disability and other med…
Tracie Lyndal Markwick, a 54-year-old woman with intellectual disability and dysphagia, died from choking on food at her day placement centre. She had a documented mealtime management plan indicating mild-to-moderate cho…
77y · Female·Complications of malnutrition in a woman with paranoid delusions
A 77-year-old woman with complex medical and psychiatric history died from complications of malnutrition while an inpatient with paranoid delusions and delirium. She was admitted following falls and required compulsory t…
78y · Female·Complications of mandibular fractures sustained in a fall, in the setting of mal…
Frances Hayden, 78, died from complications of mandibular fractures sustained in a fall at an aged care facility. She had long-standing schizoaffective disorder with associated anorexia, resulting in severe malnutrition …
52y · Female·unascertained - likely combination of underlying natural disease (myocardial inf…
Lisa Murphy, a 52-year-old woman with mental illness and substance use history, died following a physical altercation at a convenience store. She became involved in a verbal and physical confrontation with two women afte…
36y · Male·Heroin toxicity
A 36-year-old man with a history of homelessness and intravenous heroin use died from heroin toxicity after overdosing in a public toilet block. Emergency services were called promptly by a bystander who remained at the …
15y · Female·Paracetamol toxicity in the setting of Anorexia Nervosa
Olivia Evans, 15, died from paracetamol toxicity in the setting of anorexia nervosa after intentionally overdosing. She had 38 inpatient admissions over two years with escalating food refusal, self-harm, and suicidal beh…
66y · Male·Undetermined (natural causes)
A 66-year-old man with multiple chronic conditions including Parkinson's disease, spastic gait syndrome, cognitive impairment, atrial fibrillation, and swallowing difficulties died at his supported disability accommodati…
29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…
A 29-year-old man died from mixed drug toxicity involving multiple CNS depressants. His GP, Dr X, had maintained an inappropriate three-year sexual relationship with the patient while prescribing escalating doses of opio…
32y · Female·Compression of the neck
FSZ, a 32-year-old woman, was killed by her intimate partner NLU through compression of the neck (strangulation) on 24 April 2019. This coronial finding identifies multiple systemic failures in family violence response a…
61y · Male·Aspiration pneumonia in a man with cerebral palsy
John Mark Robinson, 61, died from aspiration pneumonia complicated by cerebral palsy. He presented to hospital on 29 March 2024, initially had end-of-life care initiated, then improved and was being discharged home. He s…
39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back
MJU (39) and her daughter KJH (6) were killed by MJU's husband CTH in a family violence homicide on 13-14 January 2022. CTH, who was using methylamphetamine and experiencing drug-induced psychosis with visual hallucinati…
7y · Male·multiple injuries sustained in a motor vehicle collision (passenger)
A 7-year-old boy died in a head-on motor vehicle collision after his father deliberately drove their newly purchased car into an oncoming truck. The father had recently experienced severe stress following his partner's d…
37y · Male·Multiple injuries sustained in a motor vehicle incident (driver)
A 37-year-old man died in a deliberate head-on motor vehicle collision three days after his partner died from metastatic cancer. He was the sole carer for his 7-year-old son with autism and intellectual disability. The c…
42y · Female·Unascertained; possibly mixed drug toxicity (heroin and methylamphetamine) or sm…
Tracey Ellen Knowles, aged 42, was found deceased in a vehicle on 19 July 2021 from an unascertained cause. She had a history of heroin use and experienced family violence. Police misidentified her as the 'predominant ag…
33y · Female·Respiratory sepsis in a woman with an acquired brain injury
Melanie Ranken, a 33-year-old woman with acquired brain injury from a 2017 motor vehicle accident and post-traumatic epilepsy, died from respiratory sepsis secondary to community-acquired pneumonia. She was admitted to B…
60y · Female·Pneumonia with large pleural effusion
Ms Wood, a 60-year-old woman with Down syndrome, Alzheimer's disease and epilepsy residing in specialist disability accommodation, developed pneumonia with large pleural effusion and died in hospital. A speech pathologis…
63y · Female·Natural causes unascertained; probable aspiration pneumonia with large pericardi…
Catherine Stephen, a 63-year-old woman with cerebral palsy, spastic quadriplegia, epilepsy, and kyphoscoliosis, died from natural causes unascertained at a hospice following palliative care. She had been admitted to hosp…
31y · Male·Mixed drug toxicity (heroin, bromazolam, metonitazine, protonitazene, methamphet…
Ryan Robinson, a 31-year-old man with longstanding opioid use disorder and complex mental health conditions, died from mixed drug toxicity involving heroin, novel psychoactive substances (nitazenes: metonitazene and prot…
54y · Male·Complications of pelvic and spinal fractures sustained in a fall in man with Dow…
Andrew William Barr, a 54-year-old man with Down syndrome and Alzheimer's dementia, died from complications of pelvic and spinal fractures sustained in a fall. Following his mother's death in January 2021 and his Februar…
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