1,981 results
59y · Male·Multiple injuries
Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…
32y · Female·Unable to be determined
A 32-year-old woman with obesity was prescribed Ozempic 1mg weekly in August 2024 (above the recommended starting dose) for weight management. She developed prolonged gastrointestinal symptoms and took loperamide for dia…
93y · Male·Complications of invasive squamous cell carcinoma of the scalp
Donald Morley, aged 93, died at Claire Holland House hospice on 12 July 2024 while serving a nine-year sentence for murder. He was under 24/7 custodial supervision. The cause of death was complications of invasive squamo…
69y · Female·Hydrocephalus and subarachnoid haemorrhage in the setting of a fall in a woman w…
A 69-year-old woman with cerebral palsy, intellectual disability, and B cell acute lymphoblastic leukaemia, residing in Specialist Disability Accommodation funded through the National Disability Insurance Scheme, sustain…
85y · Male·systemic sepsis due to infected right perineal ulcer and associated perianal abs…
An 85-year-old man with dementia and multiple comorbidities died of sepsis caused by an infected sacral pressure ulcer that developed and deteriorated while resident at an aged care facility. Initially assessed as stage …
66y · Male·Unable to be determined
A 66-year-old man with bipolar disorder died in an accidental house fire at his home in Bicheno, Tasmania, on 8-9 November 2024. On the evening of 8 November, following welfare concerns about his declining mental health,…
61y · Male·Ischaemic heart disease secondary to coronary artery atherosclerosis
AQ, a 61-year-old motorsport racer, died from ischaemic heart disease secondary to coronary artery atherosclerosis while competing at Phillip Island Grand Prix Circuit on 23 November 2024. In April 2024, he underwent ste…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
53y · Male·Hanging
PE, aged 53, died by hanging in Parklea Correctional Centre on 3 February 2024, four days after entering custody for the first time on remand. The coroner found PE's death was self-inflicted at a time of emotional turmoi…
54y · Female·Aspiration pneumonia secondary to Alzheimer's dementia complicating Down's Syndr…
Sandra Black, aged 54, died from aspiration pneumonia secondary to Alzheimer's dementia complicating Down Syndrome. She lived in specialist disability accommodation and had a long history of recurrent aspiration pneumoni…
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
90y · Female·Choking
A 90-year-old woman with dysphagia died from choking after consuming thin fluid (coffee) against medical recommendation. She had been reviewed by a speech pathologist on 15 November 2024 who recommended thick fluids only…
32y · Male·multiple injuries caused by a single vehicle crash
A 32-year-old man with long-standing methamphetamine addiction and drug-induced psychosis died in a motor vehicle crash on 6 January 2024. Although he received hospital treatment for severe psychosis in August 2023 and w…
40y · Male·Gunshot wound to neck
Benjamin Freear, aged 40, died from a gunshot wound to the neck sustained during a police siege on 8 December 2019 in rural Queensland. He had been diagnosed with ADHD in April 2018 and prescribed dexamphetamine by psych…
Male·Pulmonary thromboembolism and bronchopneumonia secondary to deep vein thrombosis
JNY, a man with metastatic small cell carcinoma, COPD, and ischaemic heart disease, died from pulmonary thromboembolism and bronchopneumonia. He received palliative care at home provided by his partner PJN, who had undis…
86y · Male·ischaemic and hypertensive heart disease
An 86-year-old man died of ischaemic and hypertensive heart disease while serving a prison sentence. He had multiple comorbidities including atrial fibrillation, congestive cardiac failure, and cirrhosis. The coroner exa…
38y · Female·Multiple injuries sustained when struck by a train
Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…
28y · Male·In keeping with Hanging
A 28-year-old man with a history of depression, anxiety, and previous self-harm died by hanging during a police response to a domestic violence incident. Police attended after his sister reported he had breached an ADVO …
25y · Male·Combined drug toxicity
Harrison William Ladd, 25, died from combined drug toxicity involving clonazepam, dexamphetamine, codeine, diazepam and pholcodine. He had complex mental health and substance use disorder requiring specialist addiction c…
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