3,425 results
54y · Male·Complications following an old prior cerebrovascular accident - aspiration pneum…
Gary Mayrhofer, a 54-year-old man with cerebral palsy, intellectual disability, epilepsy and visual impairment, died from aspiration pneumonia following a stroke in September 2023 that caused right-sided paralysis and sw…
57y · Male·complications of Down's Syndrome and Dysphagia - aspiration pneumonia
Leo Patrick O'Sullivan, a 57-year-old man with Down's syndrome, intellectual disability, and Alzheimer's disease, died of aspiration pneumonia in palliative care. The coroner found no evidence of inadequate clinician man…
47y · Male·Pneumonia
Shawn Farlech, a 47-year-old man with acquired brain injury from childhood encephalitis living in specialist disability accommodation, died from pneumonia with sepsis. He presented with fever on 8 April and was initially…
99y · Female·Chest injuries in the setting of a tram incident (pedestrian)
A 99-year-old woman with dementia and reduced mobility was struck by a tram while crossing at a roundabout intersection in Essendon, Victoria. She sustained severe chest injuries including bilateral pneumothoraces, haemo…
67y · Female·Head injuries
Shirley Kidd, aged 67, died from head injuries inflicted by her grandson Hayden during a cannabis-induced psychosis. Hayden had experienced severe childhood abuse by his stepfather and subsequently developed mental healt…
75y · Female·Ischaemic heart disease in the setting of unstable type 2 diabetes mellitus and …
Veronica Roberts, 75, died from ischaemic heart disease complicated by unstable diabetes and a medication error. On 4 October 2020, her insulin dose was increased to 20 units daily, but due to Electronic Medical Record (…
77y · Female·Airways obstruction by tissue paper
A 77-year-old woman with depression, anxiety, and chronic pain died from airway obstruction by tissue paper at an aged care facility. She had expressed suicidal ideation, attempted self-harm, and was found with tissues i…
27y · Male·Cyanide toxicity
Phillip Reidy, 27, died from cyanide toxicity after ingesting sodium cyanide during police arrest for a family violence incident. He had purchased 250g of sodium cyanide online from Bacto Laboratories using false informa…
94y · Female·Complications of a fractured neck of femur sustained in an unwitnessed in-hospit…
A 94-year-old woman with significant cardiopulmonary comorbidities died from complications of a fractured femur sustained in an unwitnessed hospital fall. Despite identification as high falls risk and implementation of f…
41y · Female·Cardiomegaly
Jessica Katgert, aged 41, died in custody at Dame Phyllis Frost Centre from cardiomegaly. She had a history of MSSA infective endocarditis treated in 2021 with echocardiographic changes including dilated left ventricle a…
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…
29y · Male·respiratory sepsis in a man with cerebral palsy and epilepsy
Alexander Petricca, a 29-year-old man with cerebral palsy, quadriplegia, autism and developmental delay, died from respiratory sepsis following aspiration pneumonia. He had experienced multiple respiratory episodes requi…
61y · Female·Ischaemic heart disease due to coronary artery atherosclerosis
Ms Maxine Lorraine Sanderson, a 61-year-old SDA resident with intellectual disability, died suddenly from ischaemic heart disease due to severe coronary artery atherosclerosis with critical stenosis of the left anterior …
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…
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 …
89y · Male·unascertained - natural causes
Harold Edward Burgess, aged 89, died in Port Phillip Prison's medical unit from unascertained natural causes following a fall on 6 November 2022 that resulted in cervical spine fractures. He was deemed unsuitable for sur…
40y · Male·Unascertained; probable SUDEP (Sudden Unexpected Death in Epilepsy) - natural ca…
A 40-year-old man with severe Lennox-Gastaut Syndrome and intellectual disability died unexpectedly in his sleep at a supported disability accommodation facility. He was found in a position consistent with having had a s…
58y · Male·Complications of community-acquired pneumonia, in a man with chronic lung diseas…
Adrian Phillips, a 58-year-old man with intellectual disability and chronic lung disease (emphysema, bronchopulmonary aspergillosis, asthma), died from community-acquired pneumonia caused by MRSA and Rhinovirus. He prese…
33y · Male·unascertained
Dean Jenkins, a 33-year-old with a history of drug use, disappeared on 24 August 2016 after being observed acting paranoid and erratically while substance-affected. His remains were found in a burrow near Woorinen in Feb…
0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour
Baby W died within 40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision…
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