51y · Male·Electrocution from high voltage electricity wires
…psite away from power lines, lack of formal coordination between the farmer and driver regarding power line risks, and absence of mandatory safety education and warning systems. The coroner found the death was avoidable …
2y · Male·drowning (immersion)
…er made extensive recommendations regarding pool design, lifeguard deployment, signage, supervision ratios, risk assessment protocols, and staff training to enhance child safety at public pools.
33y · Male·Drowning and head injury
Shida Li, a 33-year-old Chinese international student, drowned after being washed off rocks at Cape Schanck while rock fishing on Christmas Day 2009. He was knocked into the sea by a large wave within moments of arriving…
43y · Male·Hypoxic brain injury as a result of cardiac arrest in a setting of electrocution
Brian Glenn Milnes, a 43-year-old truck driver with 14 years industry experience, died from hypoxic brain injury following cardiac arrest when a tipper trailer he was assisting to raise contacted overhead 22,000 volt pow…
38y · Male·Mixed drug toxicity
DA was a 38-year-old man who died from mixed drug toxicity involving sedating medications and alcohol. He had longstanding severe anxiety and became dependent on codeine and benzodiazepines, initially obtained from multi…
50y · Male·Neck compression secondary to hanging
…ystemic gaps in family violence response services that, while not causally linked to his death, warrant educational attention for clinicians. Key issues included: (1) Orange Door perpetrator support services failing to …
55y · Female·Aspiration of Gastric Contents in Association with Gastric Necrosis in a patient…
A 55-year-old woman died of aspiration following gastric necrosis associated with a gastric band device inserted in 2008. She presented with vomiting and feeling unwell starting 31 October 2009, but never complained of p…
85y · Female·Complications of subdural haematoma (evacuated), secondary to fall, contributed …
Patricia Cook, 85, died from complications of a subdural haematoma following a fall at a supported residential service (SRS) while on warfarin for atrial fibrillation. She fell on 30 September 2007, striking her head. Pe…
17y · Female·Complications of acute asthma in the setting of an allergic response
…or specialist immunology assessment rather than accepting parental reassurance; the severity of anaphylaxis risk in young people with multiple food allergies should not be underestimated based on prior benign reactions; …
60y · Female·Complications of metastatic melanoma in the setting of neck of femur fracture fo…
Susan Ruth Lovell, a 60-year-old woman, died from complications of metastatic melanoma in the setting of a neck of femur fracture sustained during a fall. A skin lesion on her left calf, noted in January 2010, was clinic…
20y · Female·Drowning during the course of a crocodile attack
Isobel Von Jordan, a 20-year-old German university student, drowned during a saltwater crocodile attack at Sandy Billabong in Kakadu National Park on 22 October 2002. Tour guide Glenn Robless led the swimming group to an…
49y · Female·Bronchopneumonia, hypoxic brain injury, and combined drug toxicity (oxycodone an…
Karen Moore, aged 49, died from bronchopneumonia following hypoxic brain injury caused by combined drug toxicity (oxycodone and diazepam). She was found unconscious at home after an overdose and did not regain consciousn…
15y · Female·hanging
… The coroner found multiple systemic failures: DCJ closed cases due to "competing priorities" despite clear risks; breached Family Court orders preventing contact with her abusive mother and Nathan were known but ignored…
17y · Male·Circulatory failure caused by traumatic brain injury from being struck by a log
…uring a 'Capture The Flag' game at Mount Ainslie, near his school. Key clinical lessons: (1) The inadequate risk assessment processes meant preventable hazards were not identified. (2) Supervision ratios were insufficien…
9y · Female·complications of thermal injury
A 9-year-old child died from severe thermal injuries sustained in a house fire. The property had non-functional smoke alarms that the property management company knew about but failed to remedy or report to the landlord.…
83y · Female·Combined effects of severe malnutrition and infection (septicaemia secondary to …
Mrs Clark, 83, died from severe malnutrition and infection including septicaemia from an infected sacral pressure ulcer that had existed for 7 months. She was admitted to hospital in a deplorable state with severe pressu…
Unknown·head injuries
…nvolved, though alternative approaches such as earlier termination or discrete following might have reduced risk. Key issues identified included inadequate radio communication preventing command from receiving vital info…
Zara Schupelius: suffocation; Callum Smith: undetermined; Jake Hackett: suffocat…
Concurrent inquests into five sudden unexpected deaths in infancy (SUDI), three attributed to suffocation and two undetermined but with suffocation as a significant possibility. All deaths occurred in infants aged 2-7 mo…
0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…
Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal managemen…
60y · Male·cardiorespiratory failure due to malignant pleural effusion due to metastatic ma…
A 60-year-old man with diabetes presented with a plantar heel ulcer in March 2007 that was initially treated as a diabetic foot ulcer. The lesion failed to heal over 16 months despite standard care including wound dressi…
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