3,729 results
35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…
35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…
71y · Male·end-stage cardiac failure on a background of ischaemic heart disease with dilate…
Keith Freeman, aged 71, died in custody from end-stage cardiac failure with ischaemic heart disease and dilated cardiomyopathy. He had complex cardiac history including previous CABG, aortic valve replacement, and implan…
67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…
Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…
33y · Female·Sharp force neck and chest injuries
A 33-year-old woman was fatally assaulted by her intimate partner in July 2019 following a two-year relationship marked by documented family violence and his untreated mental health conditions. The perpetrator had a hist…
70y · Female·Asphyxia due to airway obstruction
Anna Lee, a 70-year-old retired psychiatric nurse, died from asphyxia due to airway obstruction while an inpatient in a mental health unit. She was admitted with first-episode mania with psychotic features, triggered by …
90y · Male·pneumonia complicating ischaemic heart disease
Francis William Athol Cable, aged 90, died in the Corrective Services NSW Secure Annex at Prince of Wales Hospital on 12 September 2022. He had complex medical comorbidities including ischaemic heart disease, chronic car…
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…
73y · Male·Metastatic colon cancer
Francesco Fogliaro, a 73-year-old man with intellectual disability living in supported accommodation, died from metastatic colon cancer. He was found on the floor of his bedroom on 9 August 2024 with signs of infection a…
33y · Male·sharp force injuries of the neck
Malcolm Brown, a 33-year-old Aboriginal man with a history of methamphetamine use, mental health crisis, and self-harm threats, died from sharp force injuries to his neck on 29 June 2022 following a NSW Police operation.…
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…
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…
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…
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…
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…
86y · Male·aspiration pneumonia following injuries sustained in a motor vehicle crash and p…
Kenneth Warn, 86, sustained a T12 burst fracture and bilateral pleural effusions from a motor vehicle crash on 1 March 2024 while a passenger in a Mercedes panel van. The driver suddenly lost control on Tea Tree Road; th…
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…
44y · Male·Complications following seizure on a background of acquired epilepsy; acquired b…
Anthony Dzaja, aged 44, died from complications of seizures secondary to acquired brain injury sustained in a 1997 motor vehicle accident. He had progressively deteriorated over several years with worsening epilepsy, cog…
66y · Female·Ischaemic brainstem stroke
Margaret Ann Day, a 66-year-old Specialist Disability Accommodation resident with undifferentiated hereditary ataxia, intellectual disability, and dysphagia, presented to the Emergency Department on 26 November 2024 with…
41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…
A 41-year-old woman died from frontal lobe ischaemic infarcts caused by cerebral vasospasm complicating subarachnoid haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days wit…
69y · Female·Multiple organ failure due to secondary haemochromatosis (transfusion-associated…
Mrs Vicki Dow, 69, died from multiple organ failure secondary to iron overload (transfusion-associated haemochromatosis) from treatment of myelodysplastic syndrome. She had declined iron chelation therapy for 19 months d…
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