918 results
31y · Male·acute neck compression by ligature
Steven Malcolm Williams, aged 31, died in custody at Yatala Labour Prison on 1 January 2015 from acute neck compression by ligature. He had a 12-year history of schizophrenic disorder previously managed with antipsychoti…
29y · Male·neck compression due to hanging
Nicholas Edward Bell, aged 29, died by hanging in Mobilong Prison on 29 April 2015. He had a documented history of mental illness, previous suicide attempts, substance abuse (methamphetamine, heroin, alcohol), and was as…
52y · Female·hepatic encephalopathy due to Child C cirrhosis of the liver on a background of …
A 52-year-old woman with chronic liver disease from alcohol abuse, diabetes and hepatitis C died from hepatic encephalopathy and cirrhosis. She presented to Port Pirie Medical Centre with bleeding, pain and confusion. Bl…
85y · Female·ischaemic heart disease with renal failure
Fernanda Catalano, 85 years old, died of ischaemic heart disease with renal failure at Lyell McEwin Hospital. She had suffered an unwitnessed fall at her aged care facility on 20 April 2016, was transferred to hospital w…
64y · Male·end-stage interstitial lung disease
Robert Edwin Collins, aged 64, died in Yatala Labour Prison from end-stage interstitial lung disease. He had advanced pulmonary fibrosis, recurrent pneumonia, obesity, and poor mobility. Following hospitalisation at Roya…
63y · Male·metastatic non-small cell lung carcinoma with chronic obstructive lung disease
Mr Curtin, a 63-year-old with metastatic non-small cell lung carcinoma and severe COPD, was admitted to Repatriation General Hospital on 14 August 2015 with dyspnea and confusion. His condition deteriorated with delirium…
34y · Female·Blunt force trauma on a background of contributing ischaemic heart disease
A 34-year-old Aboriginal woman died from blunt force trauma inflicted by her domestic partner over a prolonged period. Critical failures in police coordination and communication systems delayed apprehension of the perpet…
65y · Male·hypoxic ischaemic encephalopathy complicating hanging
James Nicholson, aged 65, died from hypoxic ischaemic encephalopathy following a suicide attempt by hanging while an inpatient at Noarlunga Hospital on 18 August 2015. He had undergone extensive facial cancer surgery in …
43y · Male·neck compression due to hanging
Michael David Bird, aged 43, died by hanging at his home while on home detention bail. He had a history of anxiety, depression, and chronic pain, managed by a psychiatrist (Dr T.) with weekly appointments described as hi…
40y · Male·metastatic malignant melanoma
A 40-year-old man with metastatic melanoma died at Queen Elizabeth Hospital on 2 September 2015. He had atypical nevi removed in 2009 and melanoma diagnosed in 2013, initially undergoing surgery with curative intent. How…
Unknown·Michael Russell: intracranial haemorrhage complicating surgery for right cerebra…
Two patients died following stroke interventions on 18 April 2017 at the Royal Adelaide Hospital. Michael Russell (60) died from intracranial haemorrhage following vessel perforation during thrombectomy for acute coronar…
77y · Male·multi-organ failure due to general inanition on a background of end-stage Alzhei…
Mervyn Eric Size, a 77-year-old man with end-stage Alzheimer's dementia, died from multi-organ failure due to general inanition while subject to a Level 2 Inpatient Treatment Order at Repatriation General Hospital. His c…
54y · Male·hypoxic-ischaemic encephalopathy resulting from neck compression due to entrapme…
Jorge Castillo-Riffo, a 54-year-old construction worker, died from hypoxic-ischaemic encephalopathy resulting from neck compression. While working on a scissor lift to patch post-tensioning pockets on a concrete slab edg…
53y · Male·fentanyl and oxycodone toxicity
Stephen Robert Atkins, 53, died from fentanyl and oxycodone toxicity after admission to Flinders Medical Centre for investigation of Horner's syndrome and radiculopathy. Over three days, escalating opioid doses were pres…
70y · Male·combined effects of severe pulmonary emphysema, ischaemic heart disease and rece…
A 70-year-old man with severe COPD, dementia and a history of sexually inappropriate behaviour died following an assault by another resident with dementia. The coroner found institutional failures in care standards inclu…
86y · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer
An 86-year-old man died from multi-organ failure due to sepsis from a stage 4 sacral pressure ulcer after 61 days in a regional hospital. Critical failures included delayed pressure injury risk assessment (7 days overdue…
70y · Male·aspiration pneumonia due to seizures
70-year-old man with insulin-dependent diabetes, cognitive impairment, depression, alcohol abuse history, and seizure disorder died from aspiration pneumonia following seizures while admitted under mental health legislat…
24y · Female·hypoxic brain injury secondary to hanging
Chrystal Ross, a 24-year-old woman, died by hanging in hospital in January 2015 after a catastrophic chain of communication failures and care coordination errors. She had been admitted to Mount Barker Hospital for anxiet…
49y · Male·ischaemic heart disease with coronary artery thrombosis (left main stem coronary…
Wayne Mitchell, a 49-year-old man, presented to a clinic with acute chest pain radiating to his jaw, accompanied by dizziness, diaphoresis, and dyspnoea. His symptoms resolved before ambulance arrival. The paramedics per…
46y · Male·Shotgun wound to the head (self-inflicted)
A 46-year-old male (Rodney Clavell) died from a self-inflicted shotgun wound to the head during a police siege at Marilyn's premises in Adelaide on 5 June 2014. Clavell was a high-risk wanted offender with extensive crim…
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