3,729 results
23y · Male·Multiple injuries from being struck by train
Jalen Hunter Norris, aged 23, died by suicide when struck by a train on 9 April 2021. He was experiencing paranoid delusions and had recently been arrested for criminal damage and cannabis possession after an incident at…
55y · Female·Multiple injuries sustained in a train incident
Andrea Milner, a 55-year-old woman with cerebral palsy, depression, and anxiety, died from multiple injuries sustained when she drove her motorised wheelchair off a railway platform onto tracks at Ormond station on 23 Se…
74y · Female·Infective exacerbation of chronic obstructive airways disease in the setting of …
Caroline McCormack, 74, died from infective exacerbation of chronic obstructive airways disease following a medication administration error where pregabalin was erroneously included in her Webster-pak despite being cease…
20y · Male·Drowning precipitated by a seizure
Cameron De Vries, a 20-year-old man with severe autism spectrum disorder and global developmental delay, died by drowning precipitated by a seizure in a bathtub at a disability support home. He had experienced a seizure …
73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…
Judith Pollard, a 73-year-old woman with an extensive mental health history, was voluntarily admitted to Shepparton Private Hospital on 1 June 2023 following acute depression and paranoia. Despite her family informing st…
73y · Male·Complications of multiple injuries sustained in a motor vehicle incident (car vs…
A 73-year-old man with extensive medical comorbidities including severe biventricular heart failure, COPD, sleep apnoea, and hypertension experienced a medical episode while driving, causing him to cross into oncoming tr…
43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…
A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…
Female·drowning (all three deceased)
This coronial finding examined three flood-related deaths in Tasmania during June 2016 following exceptional rainfall. Mary Allford drowned when her Latrobe home was inundated; Trevor Foster was swept away at Ouse; Peter…
62y · Male·Complications of likely sepsis in the setting of a pseudo bowel obstruction in a…
Douglas Coyle, a 62-year-old man with Hirschsprung's disease, intellectual disability, and epilepsy, died from sepsis complicating pseudo bowel obstruction. He presented to hospital on 15 June with shortness of breath, r…
46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…
A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…
46y · Male·Coronary artery disease
Mark Fava, 46, died of coronary artery disease while in custody at Port Phillip Prison. He was found unresponsive in his cell and CPR was commenced immediately, continuing until paramedic arrival. The death was from natu…
27y · Male·Multiple blunt force injuries from jumping off a cliff
A 27-year-old involuntary mental health patient absconded from a hospital transfer vehicle and subsequently died by jumping from a cliff. Critical failures included: absence of clinical assessment before transfer despite…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…
26y · Female·Multiple head, chest and limb injuries sustained in a motor vehicle crash
Danielle Kate Walker, a 26-year-old experienced driver, died in a head-on motor vehicle collision on Boyer Road, Tasmania on 3 June 2023. The crash was caused entirely by the driver of the other vehicle, Graham John Free…
67y · Male·Head injuries sustained in falls
Martin Barlow, 67, died from head injuries sustained in two falls on 5 August 2022 while intoxicated (BAC 0.17 g/100mL). He suffered subarachnoid haemorrhage and subdural haemorrhage. After Ms Burrell called emergency se…
21y · Male·Complications of injuries sustained when a trench wall collapsed
Jack Brownlee, 21, died from crush injuries sustained in a workplace trench collapse at a construction site. Despite family concerns that excavator use during rescue exacerbated his injuries, expert geotechnical and resc…
40y · Male·Aspiration pneumonia
Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia f…
90y · Male·Complications following aspiration of food
Donald Walter Thoms, 90 years old with intellectual disability and high aspiration risk, died from complications following aspiration of food while in specialist disability residential care. He was on a pureed diet and t…
30y · Female·Acute ethanol toxicity on a background of chronic alcoholism
Kathleen Arnold, aged 30, died from acute ethanol toxicity on a background of chronic alcoholism. She had a 20-year history of alcohol dependence, complex trauma from a childhood near-drowning incident, eating disorders,…
15y · Male·Combined heroin and methamphetamine toxicity
T, a 15-year-old boy subject to a Care by Secretary Order, died from combined heroin and methamphetamine toxicity on 24 November 2019. He had experienced multiple placement instability (over 20 placements in two years), …
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