403 results
48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam
A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…
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…
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…
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…
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…
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…
43y · Male·compression of the neck in keeping with hanging
A 43-year-old man on home detention died by hanging in September 2021. He had a history of epilepsy, depression, anxiety, illicit drug use, and previous suicide attempts. In the weeks before death, he presented to hospit…
59y · Male·hanging
A 59-year-old man with major depression and psychotic features was lawfully detained under an inpatient treatment order at Noarlunga Hospital's Morier Ward. He was appropriately managed, initially in the high-dependency …
20y · Male·gunshot wound to the chest
A 20-year-old man with borderline personality disorder, who had made over 25 suicide attempts in the two years prior, died from a gunshot wound sustained during a police encounter. He had called mental health services an…
74y · Female·Intracranial haemorrhages (non-operated) on a background of dementia
Frances Veronica Icke, aged 74, died from intracranial haemorrhages on a background of dementia. She fell at home on 31 December 2021 and was admitted to hospital with two brain bleeds. Neurosurgery determined she was no…
22y · Male·neck compression due to hanging
A 22-year-old man with treatment-resistant schizophrenia died by hanging while under guardianship with special powers of detention in supported independent living. He had attempted suicide by drinking bleach one month pr…
61y · Male·ischaemic heart disease with left ventricular hypertrophy
A 61-year-old Aboriginal man died in prison custody from ischaemic heart disease with left ventricular hypertrophy. He had significant cardiac risk factors including type 2 diabetes, hypercholesterolaemia, age, male sex,…
91y · Female·dementia complicated by subdural haemorrhage
A 91-year-old woman with advanced dementia under guardianship order died from dementia complicated by subdural haemorrhage. She sustained a fall at an aged care facility in July 2021, resulting in a 6mm subdural haematom…
62y · Male·end stage renal failure complicating oxalate crystal nephropathy with contributi…
Stewart Anthony Leane, 62, died from end-stage renal failure due to oxalate crystal nephropathy with contributing head injury. He had complex medical needs including dialysis-dependent kidney failure, schizophrenia, and …
76y · Male·right lower lobe pneumonia on a background of frontotemporal dementia, chronic o…
A 76-year-old man with frontotemporal dementia, COPD, and osteoporosis died of right lower lobe pneumonia following multiple falls causing pelvic and rib fractures at a nursing home. He was admitted to hospital on 9 Febr…
84y · Male·head and pelvic injuries with contributing ischaemic and valvular heart disease …
An 84-year-old man under guardianship with dementia, cardiac disease, and on anticoagulation suffered an unwitnessed fall at an aged care facility and sustained head and pelvic injuries. Following the fall, a registered …
85y · Male·blunt craniocerebral trauma following a fall
Anthony Donato, aged 85, died from blunt craniocerebral trauma following an unwitnessed fall at an aged care facility. He had dementia, hypertension, sleep apnoea, and previous falls. He was assessed as medium fall risk …
72y · Male·asphyxia due to upper airway obstruction due to choking on food
A 72-year-old man with acquired brain injury, seizure disorder, and dysphasia died from asphyxia due to choking on food while eating eggs and ham on toast at a disability care facility. He had no documented swallowing di…
54y · Male·multi-organ failure and sepsis complicating fulminant pneumonia with empyema (op…
A 54-year-old man died from sepsis and multi-organ failure secondary to fulminant pneumonia with empyema. He presented to his GP on 1 April 2021 with concerning signs including bilateral oedema, fever, and respiratory sy…
84y · Female·Alzheimer's disease with subdural haematoma from traumatic head injury as a cont…
Mrs Betty Reid, aged 84 years with advanced Alzheimer's disease, died from Alzheimer's disease with subdural haematoma from traumatic head injury as a contributing factor. She sustained an unwitnessed fall on 1 November …
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