4,987 results
19y · Male·heroin toxicity
Marshall Carter, 19, died in custody from heroin toxicity at Yatala Labour Prison. He had a long history of drug abuse starting from age 14 and was an intravenous heroin user. Critical failures included: inadequate trans…
38y · Male·neck compression due to hanging
Michael Andrew Curren, a 38-year-old prisoner at Mobilong Prison, died by hanging on 10 June 1998. He had been assaulted five days earlier and attended medical review on the day of death, but presented as being in good s…
30y · Male·cardiac arrhythmia due to therapeutic clozapine use
Edmund James Fern, aged 30, died at a psychiatric institution (James Nash House) on 4 September 1997, nine days after septoplasty for nasal obstruction. He was on multiple medications including clozapine 350mg nightly, c…
26y · Male·neck compression due to hanging
A 26-year-old Aboriginal man with longstanding borderline personality disorder, substance abuse, and multiple suicide attempts died by hanging in a psychiatric ward whilst detained under a Mental Health Act order. Key cl…
37y · Male·Traumatic intracranial haemorrhages/brain damage and fractured skull
A 37-year-old male died from traumatic intracranial haemorrhage and skull fracture after being punched and falling onto concrete. The critical clinical lesson is that head injuries may be completely undetectable on exter…
29y · Male·left cerebrovascular accident (stroke) due to thromboembolism in the middle cere…
A 29-year-old male bodybuilder died from left cerebrovascular accident (stroke) caused by thromboembolism. He had a history of anabolic steroid use and presented after a minor motor vehicle accident on 6 April 1999. Imag…
24y · Female·Immersion (drowning due to hypoxic brain injury)
Syoko Tsubaki, a 24-year-old Japanese tourist and inexperienced recreational diver, died from drowning on 31 December 1998 after a scuba diving incident at Rottnest Island on 27 December. During an afternoon dive, the di…
84y · Male·severe head injuries (fracture of skull on right side, subarachnoid haemorrhage,…
An 84-year-old man with severe respiratory disease, cardiac failure, poor vision and confusion fell from a first-floor hospital window, sustaining fatal head injuries. The coroner found the death was not deliberately sel…
4y · Female·Immersion (drowning)
Kaitlin Alyce Gubanyi, a healthy 4-year-old girl who could swim, drowned in a backyard swimming pool on 30 March 1999. While being supervised by a neighbour, Mrs Vicki Parr, the child was discovered face down in the pool…
20y · Male·ruptured heart and aorta due to fall from a height
A 20-year-old male with newly diagnosed disorganised schizophrenia died by suicide from a fall from the 5th floor of a hospital maternity building while detained under the Mental Health Act. He had been admitted to the C…
22y · Male·Ligature Compression of the Neck (Hanging)
Dean Kieran Lauder, aged 22, died on 31 May 1998 at Canning Vale Prison by ligature strangulation (hanging) while in a punishment cell. He was serving a 7-day sentence for cannabis possession offences. He had a history o…
34y · Female·hypoxic brain damage complicating fresh water drowning
Alice Louise McTye, a 34-year-old woman with severe intellectual disability and epilepsy, died from hypoxic brain damage following fresh water drowning in a bath at a disability services residence. The coroner found she …
16y · Male·Internal haemorrhage due to closed chest and abdominal injuries sustained in mot…
Todd Best, aged 16, died from internal haemorrhage following blunt chest and abdominal trauma sustained when struck by a police vehicle while evading custody. He had been arrested for property damage, placed in the front…
80y · Male·bronchopneumonia complicated by morphine toxicity
An 80-year-old man with terminal liver disease died from bronchopneumonia complicated by morphine toxicity following a medication administration error. A Graseby infusion pump was incorrectly set at 99mm/hour instead of …
0y · Female·premature delivery; extreme prematurity
A 19-week pregnant woman was admitted for pregnancy termination due to maternal psychological concerns. Labour was induced with misoprostol, expecting foetal death in utero or delivery of non-viable remains. Instead, a l…
73y · Male·dehydration and hyperthermia
A 73-year-old man with mild dementia resident in aged care wandered from the facility on a hot day (31°C+) while taking three medications with anticholinergic properties: pericyazine, haloperidol, and oxybutynin. These d…
47y · Male·Ligature compression of the neck (hanging)
Kenneth John Groth, aged 47, died by hanging in Casuarina Prison on 9 April 1998. He was a sentenced prisoner convicted of sexual offences, serving a 10-year sentence. His appeal was adjourned and legal aid was refused, …
42y · Female·salt water drowning
Sandra Sanders, aged 42, a detaineε psychiatric patient, died by saltwater drowning after absconding from Woodleigh House psychiatric unit on 3 September 1997. She had presented with major depression with psychotic featu…
27y · Female·Ligature compression of neck (hanging)
Lorna Silvester, a 27-year-old woman with depression and suicidal ideation, died by hanging on 18 January 1999 while on approved leave from Graylands Hospital. She had been admitted involuntarily on 13 January after pres…
34y · Male·aspiration pneumonia following seizure with concomitant global severe anoxic enc…
Kenneth Strangways, a 34-year-old Aboriginal man with post-traumatic epilepsy, organic brain damage from head injuries, alcoholism and psychiatric illness, died from aspiration pneumonia following a seizure. The death wa…
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