61 results
43y · Female·acute multiple drug toxicity on a background of chronic pain and morbid obesity
A 43-year-old woman died from acute multiple drug toxicity after 26 years of high-dose opioid therapy for chronic pain following a motor vehicle accident. Despite recognition by multiple clinicians that opioid doses exce…
Female·Wendy Murphy: blunt head and chest trauma. Natalie McCormack: haemorrhage follow…
Two Aboriginal women, aged 36 and 31, died following prolonged domestic violence by their partners in Alice Springs. Both had extensive histories of police-documented assaults, domestic violence orders (DVOs), and uncoop…
45y · Female·Bronchiectasis
A 45-year-old Aboriginal woman with severe bronchiectasis, COPD, and cor pulmonale died at a sobering-up shelter after police protective custody. She had 15 hospital admissions in 2015 for acute exacerbations related to …
79y · Male·Ischaemic heart disease
John Angeles, aged 79, died of ischaemic heart disease while serving a life sentence for murder. He had severe triple-vessel coronary disease, chronic lung disease, and was on maximal medical therapy. The coroner found h…
46y · Female·Cardiac arrest of unknown origin
Virginia Brown, a 46-year-old Aboriginal woman, died of cardiac arrest of unknown origin on 31 October 2014 while detained under a Mandatory Residential Treatment (MRT) order at CAAAPU (Central Australian Aboriginal Alco…
49y · Male·cardiac hypertrophy (longstanding heart disease) complicated by chronic renal fa…
Raymond McDonald, 49 years old, died in custody at Darwin Correctional Centre from cardiac hypertrophy with underlying chronic renal failure and ventricular arrhythmia. He had presented 16 times with chest pain over 12 m…
27y · Male·Coronary atherosclerosis with 80% blockage of the left anterior descending coron…
A 27-year-old Aboriginal man collapsed and died from coronary atherosclerosis (80% blockage of the left anterior descending artery) approximately 45 minutes after presenting to a remote clinic with post-exercise dyspnoea…
24y · Male·Coronary artery thrombosis secondary to coronary atherosclerosis
A 24-year-old Aboriginal man collapsed during football in extreme heat and presented to a rural clinic with dizziness, chest pain, shortness of breath and sweating. The nurse diagnosed dehydration and administered IV flu…
17y · Male·bacterial meningitis
A 17-year-old Aboriginal student died from bacterial meningitis after three clinic presentations in Yuendumu over four days. The critical failure occurred on 1 April when fever (38.3°C), persistent headache, and positive…
39y · Male·cardiac arrest caused by alcoholic cardiomyopathy
Ryan Smiler was a 39-year-old Aboriginal man who died from cardiac arrest caused by alcoholic cardiomyopathy while in custody at Darwin Correctional Centre. He had a long history of alcohol abuse, hypertension, and heart…
29y · Male·severe burns sustained in motor vehicle fire following collision
29-year-old Benjamin Wilton was killed in a horrific car fire following a rear-end collision with a vehicle driven by 67-year-old Robert Spencer on a Darwin highway. Spencer had suffered a stroke in 2003 with residual co…
55y · Male·Cardiac hypertrophy with significant conditions contributing: coronary artery at…
Eric Lewis Wobona, a 55-year-old Aboriginal man with extensive cardiovascular risk factors including congestive cardiomyopathy, coronary artery disease, hypertension, diabetes, and previous amputation, died of acute hear…
21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…
Sara Hampel, 21 years old, died from sepsis caused by necrotising fasciitis (Group A Streptococcus) on 14 October 2011, presenting 8 days post-partum with severe leg pain and multiple signs of sepsis. Critical failures i…
17y · Male·Multi-organ failure with terminal fungal sepsis (Aspergillus) on a background of…
Ben Witham, a 17-year-old with acute lymphoblastic leukaemia, died from multi-organ failure with terminal fungal sepsis. The critical issue identified was a substantial delay in investigating acute severe abdominal pain …
34y · Male·asphyxiation by hanging
A 34-year-old Aboriginal male died by suicide while on remand in prison. Despite a history of suicide attempts in 2004-2005, reception screening failed to identify suicide risk, partly because electronic alerts were not …
33y · Male·Longstanding atheromatous coronary artery disease with severe stenosis and cardi…
A 33-year-old Aboriginal man died in custody from longstanding atheromatous coronary artery disease with cardiac hypertrophy. On presentation to the prison clinic with non-specific symptoms (headache, throat pain, arm an…
33y · Male·acute hydrocephalus following ventricular blockage by a colloid cyst
Daniel Johnson, a 33-year-old Aboriginal man, died of acute hydrocephalus caused by a colloid cyst in the brain while in custody at Darwin Correctional Centre. He had complained of severe, recurring headaches for months …
16y · Female·obstructed breathing and heart arrhythmia secondary to severe obstructive sleep …
A 16-year-old Aboriginal girl with severe obstructive sleep apnoea died unexpectedly in her home one week before scheduled surgery. She had been symptomatic since age 13, but surgery was delayed for four years due to mul…
81y · Male·bronchopneumonia
An 81-year-old man with dementia, congestive cardiac failure, chronic lung disease and hip fractures died of bronchopneumonia four days after discharge from palliative care to a nursing home. While an administrative erro…
0y · Male·failure to thrive due to insufficient caloric intake
Kalib died from failure to thrive due to insufficient caloric intake at 7 weeks old. He was born to a mother with a documented history of severe neglect and physical abuse of multiple children over 5 years, during which …
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