918 results
50y · Male·Injuries sustained in a shark attack
Peter Clarkson died following a shark attack while abalone diving in coastal South Australian waters in February 2011. This finding does not involve direct medical care failures but provides important lessons about emerg…
62y · Male·extensive small cell lung cancer
Trevor John Smith, aged 62, died from extensive small cell lung cancer at Royal Adelaide Hospital on 18 March 2011. He was under Mental Health Act detention when he developed delusions and delirium during his final illne…
30y · Male·compression of the neck consistent with hanging
Christopher Aaron Smith, a 30-year-old Koorie Aboriginal man remanded in custody on serious criminal charges, died by hanging in his prison cell. A critical missed opportunity occurred in November 2009 when Mr Smith atte…
56y · Male·respiratory failure due to adenocarcinoma of the lung and chronic obstructive lu…
Neville Ronald Baker, aged 56, died from respiratory failure due to adenocarcinoma of the lung and chronic obstructive lung disease. He was a life prisoner serving a sentence for murder. He had been a heavy smoker throug…
57y · Male·multiple injuries from motor vehicle collision
Bernard Evans, aged 57, died in a motor vehicle collision on 17 January 2011 while evading apprehension under the Victorian Mental Health Act. He had schizoaffective disorder managed with lithium and olanzapine under a C…
69y · Female·left pontine haemorrhage with re-bleeding associated with hypertensive vascular …
A 69-year-old woman died from left pontine haemorrhage with re-bleeding. On 2 February 2010, her GP referred her for a CT head scan after she reported two weeks of slurred speech. The scan on 11 February revealed a ponti…
28y · Male·gunshot injury of head, self-inflicted
Jason Neil Richards, aged 28, died from a self-inflicted gunshot wound to the head on or about 21 June 2011 at Coondambo Station, South Australia. He had consumed methamphetamine and amphetamine before embarking on a lon…
1y · Female·Head injuries from crush force caused by hydraulic massage table lowering mechan…
An 18-month-old girl died from crush injuries to her head when trapped in the hydraulic lowering mechanism of a massage table at a private clinic. The child moved unobserved into the gap beneath the table while it was be…
37y · Male·compression of the neck consistent with hanging
Andrew David Hollonds, a 37-year-old man with personality disorder, substance misuse, and recent psychosis, presented to hospital after a suicide attempt (temazepam overdose) following job loss. He explicitly threatened …
0y · Female·dehydration
Olivia Johnson, an 11-month-old Indigenous infant, died of dehydration from acute gastroenteritis in a remote location. She presented to Leigh Creek Medical Clinic with 48 hours of vomiting and diarrhoea and was likely a…
69y · Male·subarachnoid haemorrhage with contributing cardiomegaly
A 69-year-old man with hypertension presented with sudden onset severe headache, photophobia, nausea and neck stiffness—classic features of subarachnoid haemorrhage. A CT angiogram identified a 6mm aneurysm on the anteri…
57y · Male·Acute renal failure complicating end stage liver cirrhosis with resultant enceph…
A 57-year-old man with end-stage alcoholic liver cirrhosis died of acute renal failure complicated by hepatic encephalopathy and coagulopathy while detained under mental health legislation. He presented with severe liver…
46y · Male·metastatic malignant melanoma
A 46-year-old man with metastatic malignant melanoma died in custody at a hospice. He was extradited from New South Wales to South Australia in April 2009 while undergoing cancer treatment. There was an 8-week delay befo…
54y · Male·Respiratory failure due to aspiration pneumonia and acute autonomic and sensory …
Norman Ebanezer John Smith, aged 54, a long-term psychiatric patient under guardianship, died of respiratory failure due to aspiration pneumonia and acute neuropathy complicating severe hyponatraemia (sodium 109). He pre…
1y · Male·hypoxic arrest due to drowning
Bryce Eddleston, aged 1 year, drowned in his family's swimming pool on 24 January 2010 after crawling through open bi-fold doors from the house to the pool edge. The pool lacked the required child-proof fencing specified…
72y · Female·Intrathecal toxicity of bupivacaine and morphine
A 72-year-old woman with terminal metastatic parotid cancer died from intrathecal toxicity of bupivacaine and morphine. She was admitted to Ashford Hospital for pain management of pathological pelvic fractures. An intrat…
61y · Female·hypoxic brain injury following cardiac arrest due to neck compression due to han…
A 61-year-old woman died from hypoxic brain injury following cardiac arrest caused by hanging on a psychiatric ward. She had been admitted after a suicide attempt by overdose and was under a Mental Health Act detention o…
32y · Male·Gunshot wound to head (self-inflicted)
Shane Andrew Robinson, a 32-year-old registered child sex offender and parolee with a long violent criminal history and substance abuse problems, died by self-inflicted gunshot wound while evading police during a siege a…
42y · Male·disseminated metastatic renal cell carcinoma
A 42-year-old prisoner died from disseminated metastatic renal cell carcinoma. Renal cancer was identified by ultrasound in September 2006 and confirmed by CT scan. Surgery was performed with curative intent in December …
58y · Male·metastatic adenocarcinomatosis with unknown primary source
A 58-year-old prisoner died of metastatic adenocarcinoma with unknown primary. In September 2006, significantly abnormal liver enzymes (GGT 2093) and hyperglycemia were detected. A December 2006 ultrasound identified an …
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