64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…
…nchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 September and 20 October 2021. Toxicology revealed oxycodone and diazepam at levels that would be lethal in femoral blood, though splenic testing …
37y · Male·cardiac arrhythmia
A 37-year-old man died in custody from cardiac arrhythmia, with morbid obesity and concurrent psychotropic medications carrying QT-prolongation risk identified as contributing factors. Key clinical lessons include: (1) p…
49y · Female·Unascertained; most likely cardiac abnormality
… interval) pose hidden cardiac risk; hourly observations may be insufficient for high-risk patients; and toxicology testing limitations mean undetected drugs cannot be excluded. Earlier family notification despite patien…
35y · Male·Multiple injuries from motor vehicle collision, with significant contributing co…
…ed following a motor vehicle collision that occurred during a police pursuit initiated at a random breath testing site. He was driving under the influence of methylamphetamine and morphine, which significantly impaired …
60y · Male·cervical spine fracture sustained in bicycle crash
…2022. He was riding downhill on a steep concrete path (24.3% gradient) when he lost control and crashed. Toxicology detected cannabis at levels consistent with recent use (within hours), which may have caused impaired co…
5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained
… 5-month-old premature infant with low birth weight died suddenly and unexpectedly at home. Toxicological testing revealed the presence of frusemide (a diuretic medication) in his blood and other samples, which should n…
42y · Male·Complications post polypharmacy toxicity
…ing suspicious patterns is critical. Post-incident reviews identified missed opportunities for urinalysis testing and additional unit searches that might have prevented the overdose.
67y · Male·Multiple injuries sustained in a motorcycle incident
…e investigation revealed that his motorcycle was fitted with a Crampbuster throttle control device, which testing suggested could interfere with front brake application during emergency braking. The deceased was experie…
Toxicity to protonitazene
…aloxone availability, public education on overdose signs, and emerging nitazene test strips to allow home testing of substances.
33y · Male·hypoxic-ischaemic encephalopathy due to hanging with resuscitation
Matthew Keith Constantine, aged 33, died from hypoxic-ischaemic encephalopathy following a hanging attempt while under home detention. He was released from prison in December 2021 with parole conditions including electro…
35y · Male·Multiple organ failure—cause not determined to requisite standard
…doramectin toxicity, paroxetine-induced serotonin syndrome, and intentional self-poisoning. Toxicological testing failed to detect farm chemicals in blood samples; autopsy revealed multiorgan failure and oesophageal ulc…
29y · Male·complete transection of the vertebral column from the base of the skull sustaine…
…ately licensed, and traveling at appropriate speed (approximately 80 km/h in a 100 km/h zone). Visibility testing confirmed that a pedestrian in dark clothing in this location would be very difficult to detect. The deat…
26y · Male·Brain death post mixed drug toxicity including MDMA and cocaine
Mr P, a 26-year-old man, died from brain death following mixed drug toxicity from MDMA and cocaine consumed at a music festival. He presented with seizures, hyperthermia (42.2°C), and rigidity at the festival medical ten…
44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…
…es: inadequate blood pressure monitoring despite explicit instructions; failure to refer for sleep apnoea testing due to a clerical error that was never caught; absence of follow-up after a serious seizure-like episode …
20y · Male·Undetermined - evidence does not support a finding as to cause of death
…eson's remains could not determine cause of death—no clear anatomical injury was found, and toxicological testing could not confirm drug overdose due to decomposition. The coroner found strong suspicion regarding Atkins…
53y · Female·Unascertained
…d not establish causation at the requisite legal standard due to lack of confirmed mechanism and forensic testing limitations. Key clinical lessons include recognition of potential psilocybin-related toxidromes, the nee…
25y · Male·Aspiration pneumonia secondary to methadone toxicity
… the medical assessment and prescription decisions, though lacking formal assessment tools and urinalysis testing, fell within acceptable clinical practice given the doctor's experience and Steven's reported withdrawal …
53y · Male·Mechanical asphyxia in the setting of a motor vehicle incident (driver)
…sphyxia when his vehicle left a rural highway near a right-hand bend with poor road design. Toxicological testing revealed cannabis at 59 ng/mL (elevated concentrations). The driver also had severe coronary atherosclero…
25y · Female·Undetermined
…20 years of investigation. The coroner recommended referral to the Unsolved Homicide Team for further DNA testing and expert analysis of cause of death.
18y · Male·Drug toxicity (3,4-methylenedioxy-N-methylamphetamine (MDMA), methylone)
An 18-year-old male died from drug toxicity (MDMA and methylone) following ingestion at a music festival. He collapsed 4 hours after consuming three MDMA capsules over one hour, suffered cardiac arrest at the festival me…
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