329 results for “delivery”
24y · Male·Multiple gunshot wounds
Mohamad Ikraam Bahram, a 24-year-old man with schizophrenia managed under a community treatment authority, died after being shot by police on Mary Street Brisbane following an unprovoked assault on a tourist. He had pres…
29y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to out of hospital …
Wayne Fella Morrison, a 29-year-old Aboriginal man with undiagnosed coronary artery disease (70% stenosis of right coronary artery), died following cardiac arrest during his detention at Yatala Labour Prison. After attac…
27y · Male·hydrocarbon inhalation
This inquest involved three deaths from petrol inhalation (1999-2001) on the Anangu Pitjantjatjara Lands. All three deceased were chronic sniffers (10+ years) who died from respiratory depression/asphyxia with distinctiv…
38y · Female·complications following a ruptured ectopic pregnancy
Veronica Campbell, age 38, died on 31 December 2008 from complications of a ruptured ectopic pregnancy. She presented to Cobram District Hospital with severe pain and was diagnosed with a possible ectopic pregnancy requi…
15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…
Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…
34y · Male·aspiration pneumonia following seizure with concomitant global severe anoxic enc…
…k of appropriate secure accommodation for complex patients; and inadequate cultural competence in service delivery. The coroner found that Mr. Strangways' cognitive impairment prevented him from making informed choices a…
42y · Female·Pneumonia, underlying severe cerebral palsy
Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…
21y · Male·Closed head injury and retroperitoneal and pelvic haematoma due to fractured pel…
A 21-year-old man died from massive internal bleeding into the pelvis and retroperitoneum following a motor vehicle collision with a stobie pole in rural South Australia. He was trapped for over 2 hours before extricatio…
26y · Male·gunshot wound to the neck
Detective William Crews, aged 26, was fatally shot during a search warrant execution in Bankstown on 9 September 2010. He was unintentionally shot by fellow officer Detective Roberts while conducting a basement search fo…
35y · Female·homicide by smothering/suffocation, possibly facilitated by chloroform exposure
This tragedy involved the deaths of Preetika Sharma (35), her two children (Divesh, 5; Divya, 3), and her husband Nilesh, who killed his family and then himself. Mr Sharma exposed family members to chloroform before smot…
18y · Female·Multiple fractures of the skull, separation of C2 and C3 and generalised cerebra…
Sarah Waugh, aged 18, died on 24 March 2009 following a fall from a horse (Dargo) during a Jackaroo/Jillaroo course at TAFE NSW Western Institute Dubbo. The coroner found multiple critical systemic failures: TAFE impleme…
33y · Male·stab wound to the chest
…d medication. Systemic failures in risk assessment, searching procedures, cell management, and healthcare delivery created conditions enabling this preventable death.
37y · Male·Respiratory arrest in association with medication drug effect and alcohol intoxi…
David James Lee, a 37-year-old Aboriginal man with schizophrenia, died on 15 July 2007 at Port Hedland Regional Hospital from respiratory arrest associated with medication effect and alcohol intoxication. He arrived at t…
78y · Male·pneumonia with dehydration and exposure to heat as contributing factors
Peter Limbunya, a 78-year-old Aboriginal elder, died from pneumonia complicated by dehydration and exposure after being left unattended at a remote airstrip following hospital discharge. He was not accompanied by a requi…
Male·Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposure in cont…
…ion. The coroner emphasised this was preventable through better social support, coordination, and service delivery.
4y · Female·hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to…
Aurora Sleep died from hypoxic-ischaemic encephalopathy caused by uterine rupture during labour induction with prostaglandin gel. Her mother had a perforated uterus from a D&C procedure 9 months earlier. The coroner foun…
26y · Male·Multi-organ failure due to pneumococcal septic shock
A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…
0y · Female·Intracranial and intrapulmonary haemorrhage due to traumatic head injury from fa…
…re head injury, better prenatal management and equipment maintenance could have prevented the precipitous delivery and fall.
gunshot wounds; multiple deaths during police interventions with mentally ill in…
…d they faced imminent threats. However, the coroner identified systemic failures in mental health service delivery that contributed to the crises. Key issues included: inadequate assessment procedures disregarding family…
3y · Female·Undetermined, consistent with suffocation or drowning
Indianna Grace Price-Mihayo, aged 3 years, was killed by her father Charles Mihayo on 20 April 2014 during a custody visit, in a case of filicide within a context of family violence and parental conflict. The death occur…
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