918 results
19y · Female·asphyxiation
A 19-year-old university student with chronic bilateral uveitis presented to university counselling with depression. She disclosed detailed written suicide plans (helium asphyxiation) to the Head of Counselling, who appr…
Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: in…
Three neonates died following complications during planned homebirths attended by midwife Lisa Barrett. Tate Spencer-Koch (4790g, macrosomic) died from intrapartum hypoxia caused by shoulder dystocia; delivery was obstru…
20y · Female·head and vertebrae injuries from falling tree branch
Rebecca Jolly, aged 20, died from head and vertebral injuries when a 7-metre limb from a large grey box tree dropped onto her car on Greenhill Road, Adelaide in January 2010. The tree was on council-managed roadside verg…
24y · Male·neck compression due to hanging
A 24-year-old man with depression and anxiety died by hanging in March 2009, three weeks after hospital discharge following an overdose. Critical clinical lessons emerge: (1) discharge summaries from psychiatric admissio…
56y · Female·multi-organ failure complicating severe burns on a background of alcoholic liver…
A 56-year-old woman with alcoholic liver disease, cerebellar atrophy, and marked mobility impairment suffered fatal full-thickness burns (75% TBSA) from scalding shower water at Flinders Medical Centre. She was left unat…
10y · Female·congenital hydrocephalus
Amber Jayne Sweetman, aged 10, died from complications of congenital hydrocephalus following delayed diagnosis of a blocked ventriculoperitoneal shunt. She presented to the emergency department with seizures and raised i…
56y · Male·disseminated nocardiosis involving central nervous system, kidneys, liver and th…
Allan Kenneth Miller, 56, died from disseminated nocardiosis (rare bacterial infection) that was not diagnosed during his 12-day RAH admission. Clinicians initially suspected metastatic lung cancer based on presentation …
24y · Male·Blood loss due to multiple stab wounds to chest and multiple incised wounds of n…
A 24-year-old man with schizoaffective disorder and substance abuse killed his 2-year-old son and himself in March 2009. The deceased had been released on licence following a mental impairment finding and was subject to …
45y · Female·Robyn Eileen Hayward: gunshot wound to the head; Edwin Raymond Durance: gunshot …
This inquest examined two deaths from gunshot wounds in domestic violence context. Robyn Hayward (45 years) was shot by her estranged partner Edwin Durance (62 years), who was subsequently shot by police. Critical failur…
61y · Male·ischaemic heart disease with significant atherosclerotic narrowing of all three …
Lindsay Allan Fry, a 61-year-old prisoner with poorly controlled Type II diabetes, died of ischaemic heart disease while in custody at Yatala Labour Prison. Autopsy revealed marked coronary artery atherosclerosis, myocar…
41y · Male·acute neck compression due to hanging
Simon Christopher Hynes, aged 41, died by hanging between 7 June and 5 July 2007, shortly after discharge from hospital on leave of absence under a Mental Health Act continuing detention order. He had a 20-year history o…
72y · Male·inanition of terminal metastatic carcinoma of the left lung
A 72-year-old man with chronic mental illness detained under the Mental Health Act died of inanition from terminal metastatic lung cancer at an aged care facility. He had advanced lung disease from chronic smoking and wa…
39y · Male·cardiomegaly
Matthew Tyson Swavley, aged 39, died suddenly from cardiomegaly while detained under the Mental Health Act at Lyell McEwin Health Service. He had chronic schizophrenia managed with antipsychotics and was morbidly obese (…
89y · Female·acute renal failure with severe electrolyte disturbance due to sigmoid volvulus …
An 89-year-old woman with severe vascular dementia died from acute renal failure due to sigmoid volvulus while detained under the Mental Health Act. She was admitted to hospital for management of aggressive behaviour sec…
40y · Male·large bowel obstruction complicating disseminated carcinoma of rectum
A 40-year-old male died in prison custody from large bowel obstruction complicating disseminated rectal carcinoma. He had been diagnosed with adenocarcinoma in 2004, treated with radiotherapy and chemotherapy, with progr…
82y · Female·acute pyelonephritis complicating base of bladder malignancy
Joyce Binch, 82, died of acute pyelonephritis from bladder malignancy while detained under mental health legislation. She was admitted with urinary tract infection, anaemia, acute renal failure, and acute exacerbation of…
40y · Male·multiple injuries from fall from building
Mark Douglas Springgay, a 40-year-old man with chronic schizophrenia, died from multiple injuries sustained after falling from the Transport SA building in Walkerville on 19 April 2008. He was on approved leave of absenc…
62y · Male·Ischaemic heart disease due to coronary atherosclerosis
Peter Albert Begg, a 62-year-old prisoner, died of ischaemic heart disease due to severe coronary atherosclerosis with contributing dothiepin toxicity. He collapsed while pushing a food trolley and did not respond to res…
52y · Female·haemorrhage from a tracheal-innominate artery fistula complicating a tracheostom…
A 52-year-old woman died from catastrophic haemorrhage due to a tracheal-innominate artery fistula 10 days after percutaneous tracheostomy following stroke and decompressive craniectomy. Minor bleeding was observed 3 day…
Multiple: pneumonia with cardiomyopathy (Kugena female); septic shock from pneum…
Concurrent coronial inquests into six Aboriginal deaths in Ceduna, South Australia between 2004-2009. All deceased had severe alcohol addiction and comorbidities including pneumonia, cardiomyopathy, liver disease, and se…
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