34 results
30y · Male·mixed butane, isobutane and propane toxicity
Justin Lee Gibson, a 30-year-old Indigenous man on home detention bail, died from inhalation of butane/propane causing fatal cardiac arrhythmia. He had a documented history of substance abuse (alcohol, cannabis, and buta…
Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…
Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…
76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…
Mrs Cook, a 76-year-old woman, died in January 2010 from hospital-acquired pneumonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangerously…
Female·intra-partum hypoxic event secondary to shoulder dystocia with prolonged foetal …
Tate Spencer-Koch was delivered via homebirth at 5:40am after her head crowned at 5:20am with shoulder dystocia causing entrapment in the birth canal for approximately 20 minutes. During this period, the foetus remained …
35y · Female·pulmonary thrombo-emboli
A 35-year-old woman with treatment-resistant schizophrenia detained under Mental Health Act died from pulmonary thromboembolism while an inpatient in a psychiatric ward. In the final days, she reported leg pain and possi…
77y · Male·hypoxic-ischaemic encephalopathy and cerebral infarction due to upper airway obs…
A 77-year-old man with advanced dementia died from hypoxic-ischaemic encephalopathy caused by upper airway obstruction from a handkerchief. An agency carer placed a handkerchief in his breast pocket during morning care, …
59y · Male·ischaemic heart disease due to coronary atherosclerosis
Brian Raymond Turner, 59, died from ischaemic heart disease due to coronary atherosclerosis following an out-of-hospital cardiac arrest in a medical clinic car park. He experienced symptoms of chest discomfort and breath…
63y · Male·uncontrolled haemorrhage from ruptured aortic aneurysm
A 63-year-old man presented with sudden back pain on 6 March 2004. Ambulance officers attended twice; on the first visit they did not transport him to hospital despite his request, misattributing his symptoms to musculos…
37y · Male·dehydration/heat-related death
A 37-year-old man died from dehydration and heat-related illness after collapsing in a sweat lodge during a vision quest ceremony in remote South Australia. He remained unconscious after removal from the lodge, but the g…
16y · Female·intra-abdominal haemorrhage due to ruptured spleen
A 16-year-old girl died from intra-abdominal haemorrhage due to ruptured spleen following a car rollover. She was transported by ambulance to the nearest hospital (Renmark) rather than the better-equipped Berri Hospital,…
81y · Female·aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphy…
Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive heart failure. A critical ambulance transfer delay …
73y · Male·ischaemic heart disease due to coronary atherosclerosis
A 73-year-old man found a purse at a shopping centre and attempted to leave his details with the information desk rather than hand it in directly. A security officer, believing him suspicious, confronted, accused him of …
18y · Male·left haemopneumothorax due to traumatic rupture of the lower lobe of the left lu…
An 18-year-old male riding a motorcycle died when the vehicle crashed into a culvert while being pursued by police. The deceased was riding whilst disqualified from holding a licence and fled from police at moderate spee…
29y · Male·hanging
A 29-year-old man remanded in custody at Adelaide Remand Centre died by hanging on 15 January 2000. At admission, he denied self-harm risk and psychiatric history; no warning signs were identified. He was found hanging f…
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