62 results
36y · Male·ligature compression of the neck (hanging)
A 36-year-old man with schizoaffective disorder, traumatic brain injury, and substance use disorder died by ligature while an involuntary inpatient in a locked mental health ward. He was on hourly observations and had re…
0y · Female·Complications of spinal muscular atrophy
Frankie Skye Foulkes, a four-month-old diagnosed with spinal muscular atrophy type 1, died from complications of SMA while positioned in a standard car seat during a car journey. She had recently commenced nusinersen tre…
2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…
A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…
82y · Female·traumatic closed head injury (subdural haematoma) resulting from a fall from sta…
Mrs Emily Jones, 82, died from subdural haematoma following an unwitnessed fall at Royal Hobart Hospital on 15 November 2021. She was admitted five days after discharge from Hobart Private Hospital where she was treated …
65y · Female·Unascertained
Jennifer Thomas, a 65-year-old woman with intellectual disability due to phenylketonuria, died in disability residential care. She became unresponsive in her wheelchair and staff performed emergency CPR after lifting her…
75y · Female·Plastic bag asphyxia in the setting of blunt force head injury
EW, aged 75, died from asphyxiation in July 2019 after being struck by her husband MW, who then took his own life. EW had advancing dementia and severe mobility limitations, with MW as her sole carer. The coroner found t…
8y · Male·multiple injuries sustained when struck by a truck on the M1 Pacific Motorway
Riley Shortland, an 8-year-old with severe autism spectrum disorder, global development delay, and ADHD, died when struck by a truck on the M1 Motorway after escaping from a vehicle during respite care. He removed his se…
65y · Female·bowel cancer
Gillian Patricia Johnston, aged 65, died from bowel cancer at her home in Wangaratta on 27 December 2020. She was residing in disability support accommodation provided by Scope Australia. Ms Johnston had received appropr…
59y · Male·Choking asphyxia
Tom Owen Row, a 59-year-old man with intellectual disability, dementia, Fragile X Syndrome, and Chromosome 18 Deletion Syndrome, died from choking asphyxia at a residential care facility. He had a prior choking incident …
72y · Female·subdural haemorrhage sustained from a fall from a hospital bed on 18 January 201…
Mrs Judith Gaye Flynn, aged 72, died from a subdural haemorrhage sustained when she fell from a hospital bed on the General Medicine Ward at Canberra Hospital. She was a high-risk fall patient with cognitive impairment, …
54y · Female·unascertained
Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…
55y · Female·Aspiration pneumonia in a woman with cerebral palsy (spastic quadriparesis)
Raylene Barbara Armstrong, a 55-year-old woman with cerebral palsy, spastic quadriparesis, dysphagia and achalasia, died from aspiration pneumonia. She had a complex medical history requiring pureed foods and thickened f…
42y · Male·Upper airway obstruction (choking) in an obese man with atherosclerotic heart di…
Andre Walter Bond, a 42-year-old man with schizophrenia, schizoaffective disorder, Asperger's syndrome, and severe obesity, died from upper airway obstruction (choking) on food while dining at home. He had been recently …
42y · Female·Neck compression due to self-suspension
Joanne Finch, a 42-year-old woman remanded in custody on charges related to her son's death, died by hanging in her cell at Dame Phyllis Frost Centre on 24 July 2018. She had chronic suicidal ideation with periods of acu…
Female·Hanging
This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral…
7y · Female·aspiration pneumonia leading to multi-organ failure in a female child with compl…
A child with severe cerebral palsy, hypoxic ischaemic encephalopathy, microcephaly and seizure disorder died of aspiration pneumonia leading to multi-organ failure. Born with severe perinatal brain injury, she had comple…
13y · Female·Hanging
Melissa Standen, a 13-year-old with profound physical and cognitive disabilities (mosaicism), died from hanging at Westmead Children's Hospital after falling from a hospital bed at Allowah respite facility. She became en…
88y · Female·Multiple injuries (neck, chest, abdomen)
June Shirley Dangerfield, 88 years old, died from multiple injuries after a motor vehicle collision on 22 November 2016. She had been declared unfit to drive by her GP following pneumonia and sepsis in early 2016, but su…
41y · Male·Sudden unexpected death in epilepsy (SUDEP)
Rohan Grindrod, a 41-year-old man with acquired brain injury and epilepsy following a 2007 motor vehicle accident, died of Sudden Unexpected Death in Epilepsy (SUDEP) at his home on 16-17 November 2011. He had a Personal…
41y · Male·Cerebral hypoxia and bronchopneumonia; contributing factors: toxic megacolon, ce…
David Orton, a 41-year-old man with cerebral palsy, intellectual disability, and severe kyphoscoliosis, died from cerebral hypoxia and bronchopneumonia complicated by toxic megacolon and Salmonella infection. Over 18 mon…
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