238 results
61y · Male·Drowning
Peter Boyle, 61, drowned in McMillan Strait after jumping into water to free a sail line entangled in his yacht's propeller. He had Parkinson's disease affecting balance and swimming ability, wore only underwear without …
5y · Male·acute upper airway obstruction from nectarine stone
Lucas Mazzei, aged 5 years, died on 27 March 2017 from acute upper airway obstruction caused by an uncut nectarine stone. While attending school, he was separated from his class during a science lesson and left watching …
73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…
A 73-year-old man presented to ED with acute facial droop and speech difficulty on 5 September 2020. He was misdiagnosed with Bell's palsy despite clinical features suggestive of stroke. A non-contrast CT brain (inadequa…
61y · Male·Pulmonary aspiration of gastric contents (post seizure) due to chronic communica…
Michael Phillip Hyde-Wyatt, aged 61, died from pulmonary aspiration of gastric contents following a seizure. He had chronic communicating hydrocephalus and encephalomalacia. At 1:30am, support worker Julie Magrath observ…
34y · Female·Multi drug toxicity
Jodie Overstead, a 34-year-old with epilepsy, anxiety, and chronic pain, died from multi-drug toxicity involving tramadol, codeine, amitriptyline, benzodiazepines and other drugs. She engaged in 'doctor shopping', obtain…
36y · Male·Bronchopneumonia in a man with epilepsy
Jonathan Palmer, a 36-year-old man with epilepsy and intellectual disability living in a group home, died from bronchopneumonia on 24 February 2018. On 23 February, he developed respiratory symptoms (coughing, runny nose…
33y · Male·Prolonged epileptic seizure resulting in gastric content aspiration and cardiac …
Roy Roberts, a 33-year-old Aboriginal man, died at Long Bay Correctional Complex from a prolonged epileptic seizure resulting in aspiration and cardiac arrest. He had experienced three prior seizure-like episodes in Apri…
72y · Female·Pneumonia following cervical spine injuries sustained in an unwitnessed mechanic…
Valma Ann Tweedie, aged 72, died from pneumonia following cervical spine injuries sustained in an unwitnessed fall at a disability support facility. She had a known history of falls, mobility problems, and probable demen…
50y · Male·Hanging
A 50-year-old man with Parkinson's disease died by hanging in a psychiatric inpatient unit while on a Temporary Treatment Order. His mental and behavioural symptoms were secondary to Parkinson's disease and its treatment…
19y · Male·unable to be determined
Nazrawi Woldemichael, a 19-year-old with a history of severe mental illness, traumatic brain injury, suicidal ideation, and substance abuse, disappeared on 9 October 2016 from North Hobart. The coroner determined he is d…
0y · Male·Perinatal hypoxia
An 8-day-old neonate died of perinatal hypoxia on 14 December 2019, 8 days after emergency caesarean section. The infant presented with seizures, hypotonia, and severe encephalopathy. Autopsy revealed severe global cereb…
0y · Female·Drowning
An 11-month-old girl drowned in a backyard koi fishpond after gaining access to the pond's edge, likely attempting to view the fish. Despite immediate CPR and rapid hospital transfer, she suffered hypoxic-ischaemic brain…
63y · Female·Escherichia coli septicaemia in a lady with multiple comorbidities
Helen Welsh, 63, died from E. coli septicaemia with multiple comorbidities. She presented with respiratory symptoms and underwent bronchoscopy. On discharge day, she deteriorated with fever, altered consciousness, and hy…
74y · Female·Complications of carotid artery injury from central line insertion in the settin…
Susan Royals, a 74-year-old woman with metastatic colon cancer, died from complications of carotid artery injury sustained during central venous catheter (CVC) insertion as part of a Whipple procedure and hemicolectomy. …
33y · Male·multiple gunshot wounds to the head, trunk and limbs
Daniel King died following multiple gunshot wounds sustained during a police operation. He had acquired a firearm and attended three locations in western Sydney, discharging it before arriving at Penrith Police Station w…
57y · Male·brainstem and cerebellar infarction due to vertebrobasilar artery thrombosis
A 57-year-old man with multiple cardiovascular risk factors presented to an ED with vertigo, blurred vision, and 'not feeling right' caused by an evolving posterior circulation stroke. A junior doctor discharged him afte…
51y · Female·Aspiration in the setting of end stage down syndrome
Catherine Ann Collier, a 51-year-old woman with Down syndrome, end-stage hydrocephalus, and severe dysphagia, died from aspiration pneumonia following a choking episode while eating. The Disability Services Commissioner …
0y · Male·Acute traumatic head injury (non-accidental)
A 7-month-old child died from acute traumatic head injury sustained from non-accidental blunt force. Clinical lessons include: medical staff should strongly reinforce urgent referrals (the child had a critical GP referra…
73y · Male·Haemorrhagic stroke in the setting of recent inguinal hernia surgery and change …
Paul Turner, 73-year-old with atrial fibrillation and aortic valve replacement, underwent elective bilateral inguinal hernia repair in August 2018. His cardiologist advised ceasing rivaroxaban 3-4 days preoperatively; ho…
40y · Male·Sudden Unexpected Death in Epilepsy (SUDEP) resulting from post-traumatic brain …
Shane Masters died from Sudden Unexpected Death in Epilepsy (SUDEP) 12 years after sustaining a severe traumatic brain injury at work. On 19 May 2008, a hydraulic jack dislodged while repairing a fully loaded truck in a …
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