4,987 results
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…
18y · Male·compression of the neck in keeping with hanging
An 18-year-old Aboriginal man died by hanging three days after release from prison on home detention bail. He had been displaying acute psychotic symptoms while in prison custody, placed under camera observation due to s…
59y · Male·Shotgun wound to the head
A 59-year-old man with a work-related shoulder injury developed anxiety and depression, later expressing suicidal ideation during mental health treatment. His general practitioners and psychologist provided appropriate m…
44y · Male·unascertained - may have been injury from fall, drowning, or predation from mari…
David Ingram, a 44-year-old deckhand, disappeared from the cargo vessel Maersk Mover on 24 September 2021 in the Indian Ocean off Exmouth, WA. He had an undiagnosed paranoid schizophrenia with a history of anxiety, depre…
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…
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…
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…
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…
53y · Male·Acute myocardial infarction due to triple vessel atherosclerosis and thrombosis …
A 53-year-old man with chest pain on exertion presented to his GP in March 2022. Initial investigations (blood tests, chest X-ray) were ordered but follow-up was delayed until July 2022. A cardiology referral was made, a…
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…
58y · Male·unascertained
Peter James Guidera, a 58-year-old man with a history of depression, suicidal ideation, and previous suicide attempts, disappeared on 8 May 1998 from Narrogin, Western Australia, shortly after receiving a distressing pho…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
Unknown·Toxicity to protonitazene
Four people died from protonitazene toxicity on 24 June 2024 after inhaling what they believed was cocaine but which was adulterated with protonitazene, an extremely potent synthetic opioid (100 times more potent than he…
Unknown·Toxicity to protonitazene
Four adults died on 24 June 2024 from protonitazene toxicity after purchasing drugs believed to be MDMA and cocaine in Melbourne. Protonitazene is a novel synthetic opioid 100 times more potent than heroin that has conta…
Toxicity to protonitazene
Four adults died on 24 June 2024 following inhalation of cocaine adulterated with protonitazene, a novel synthetic opioid 100 times more potent than heroin. Michael Hodgkinson purchased drugs believed to be MDMA and coca…
Unknown·Toxicity to protonitazene
Four adults died on 24 June 2024 from protonitazene toxicity after ingesting illicitly purchased drugs they believed to be MDMA and cocaine. Protonitazene is a novel synthetic opioid approximately 100 times more potent t…
89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…
An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
40y · Male·septic complications from injuries received from multiple dog bites sustained on…
Colin Amatto, a 40-year-old Yuin man, died from septic complications following a devastating dog attack with over 80 bite wounds. Critical clinical lesson: the same dog (Boof, a Staffordshire Bull Terrier) had attacked a…
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