138 results
73y · Female·Multi organ failure due to adhesions related bowel perforation (surgically treat…
Sharyn Kaine, a 73-year-old woman, died from multi-organ failure due to adhesions-related bowel perforation and paracetamol-induced liver failure. She was prescribed intravenous paracetamol 1g four times daily post-opera…
Female·Multiple injuries sustained in a motor vehicle collision
Two teenage girls, Claire Sankey (15) and Susanna Kopysiewicz (14), died in a motor vehicle collision on the Monaro Highway on 9 October 2022. An unlicensed learner driver, operating without a supervising licensed driver…
0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…
Baby X, born at Canberra Hospital after a prolonged labour, died at age 2 days from injuries sustained during birth. Two interlinked pathologies contributed to death: hypoxic-ischemic encephalopathy (HIE) from prolonged …
27y · Male·suicide by hanging
Luke Anthony Rich, age 27, died by suicide by hanging in a prison cell in the Alexander Maconochie Centre (ACT) on 1 February 2022, one day after being remanded in custody on domestic violence allegations. The coroner fo…
34y · Female·multiple drug toxicity
Katherine Alexander, a 34-year-old woman with chronic suicidality and complex mental health conditions including bipolar II disorder, borderline personality disorder, and PTSD, died from multiple drug toxicity on 7-8 Feb…
39y · Female·multiple drug toxicity (etizolam and carisoprodol as major components)
Catherine Broadbent, 39, died from multiple drug toxicity involving benzodiazepines (etizolam, carisoprodol) sourced from the dark web, in the context of chronic borderline personality disorder and complex PTSD with life…
Unknown·Self-inflicted gunshot wound; suicide
Three Australian Federal Police (AFP) appointees died by suicide using AFP-issued firearms: Richard Roberts (57, PSO), Samantha Baglin (44), and Dominic Coleman (52, ASO). All three had untreated mental health conditions…
23y · Male·Drowning
Najeebullah Rafee, a 23-year-old ANU international relations student and Afghan refugee, drowned on 25 October 2020 at Cotter Bend, a promoted ACT river recreation area. A non-swimmer, he attempted to use a small flotati…
46y · Male·Acute purulent pericarditis as a consequence of an infected injection, in the co…
A 46-year-old man with schizophrenia and long-standing methamphetamine use died of acute purulent pericarditis secondary to a self-administered infected injection. He was subject to a Psychiatric Treatment Order at the t…
67y · Female·ischaemic heart disease
Merren Elizabeth Bartley, a 67-year-old woman with schizophrenia managed with clozapine and multiple comorbidities including coronary artery disease, died of ischaemic heart disease while an inpatient at a mental health …
43y · Female·Complications of morbid obesity, including progressive respiratory and cardiac f…
Nicole Abbott, 43, died from complications of morbid obesity (BMI 54.4) including progressive respiratory and cardiac failure, exacerbated by smoking and obstructive sleep apnoea. She was subject to a Psychiatric Treatme…
90y · Female·acute bronchopneumonia caused by Staphylococcus aureus
Ruth McKay, 90, died of acute bronchopneumonia after accessing the external courtyard of the Memory Support Unit (MSU) at an aged care facility undetected in the early morning of 17 January 2015. She was found under a st…
62y · Male·Severe crush injuries sustained when struck by the boom of an overturned crane
Herman Holtz, a 62-year-old tower crane operator, died on 4 August 2016 when crushed by an overturned mobile crane at a university construction site. The crane operator, inadequately trained and unfamiliar with the site,…
17y · Male·Circulatory failure caused by traumatic brain injury from being struck by a log
Christiaan Adriaan Roodt, a 17-year-old Year 10 student, died from traumatic brain injury when struck by a 6-metre log during a 'Capture The Flag' game at Mount Ainslie, near his school. Key clinical lessons: (1) The ina…
23y · Female·Hypoxic-ischaemic brain damage due to self-inflicted hanging with intention of t…
Brontë Haskins, aged 23, died by suicide via hanging on 18 February 2020, three days after her release from custody on bail. The inquest identified multiple systemic failures in supervision, assessment, and coordination …
79y · Female·medication related cardiac arrest (verapamil and propranolol) in a patient with …
Mrs Patricia Croxon, a 79-year-old admitted with community-acquired pneumonia, died from medication-related cardiac arrest caused by verapamil and propranolol. The verapamil was charted in immediate release form when she…
18y · Male·asphyxia by hanging; intentional self-harm
Joshua, 18, died by suicide at an ANU residential hall in August 2018, several weeks after a serious self-harm incident requiring hospitalisation. Key clinical lessons emerge: (1) Inadequate coordination between ACT Ment…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…
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, …
25y · Male·Cardiorespiratory arrest due to aspiration pneumonia and hypoxic-ischaemic encep…
Dean Brice, aged 25, died from accidental multiple drug toxicity (methamphetamine and GHB) causing cardiorespiratory arrest, aspiration pneumonia and hypoxic-ischaemic encephalopathy. He was subject to a Psychiatric Trea…
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