397 results
62y · Male·cardiac arrest complicating psychotic episode
Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applie…
17y · Female·multiple injuries
Afrikah Rose Pearl Philp, aged 17, died from multiple injuries sustained in a high-speed vehicle collision on 6 October 2017 while being pursued by police. She had a complex medical history including psychogenic non-epil…
43y · Male·compression of the neck due to hanging
A 43-year-old male veteran died by hanging in a psychiatric inpatient unit while under a Level 2 Inpatient Treatment Order. He was admitted after a high-lethality suicide attempt involving overdose and carbon monoxide ex…
89y · Female·head injury
Barbara Ann Haynes, aged 89, died from a head injury sustained in a fall at an aged care facility on 29 March 2020, with death occurring 13 days later on 11 April 2020. She had Alzheimer's dementia, osteoporosis, and a h…
41y · Male·undetermined
Vaughan Weston Williamson, 41, died at Glenside Hospital while subject to a Level 3 Inpatient Treatment Order for treatment-resistant schizophrenia. Despite post-mortem examination including specialist neuropathological …
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 …
29y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to out of hospital …
Wayne Fella Morrison, a 29-year-old Aboriginal man with undiagnosed coronary artery disease (70% stenosis of right coronary artery), died following cardiac arrest during his detention at Yatala Labour Prison. After attac…
27y · Male·hanging
A 27-year-old man with deteriorating mental health and acute psychotic symptoms died by hanging from a bathroom door in an acute mental health unit. He had expressed suicidal ideation, told his parents he needed to die t…
Female·haemopericardium due to aortic dissection (all three cases)
Three elderly women died from acute aortic dissection at Queen Elizabeth Hospital, South Australia. Beverley Coats (73) presented three times in July 2016 with back pain, nausea and vomiting; her known aortic dilatation …
72y · Male·acute cerebral infarction complicating acute myocardial infarction
Ronald Bromage, aged 72, died from acute cerebral infarction complicating acute myocardial infarction. He presented with chest pain on 22 and 25 February 2016 to his GP, Dr P., who diagnosed costochondritis without perfo…
50y · Male·ischaemic heart disease
Paul Reid, a 50-year-old Aboriginal man with severe ischaemic heart disease and poor medication compliance, died of a cardiac arrhythmia during his arrest by South Australian Police. He was highly intoxicated (BAC 0.25%)…
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…
53y · Male·lung abscess with empyema
A 53-year-old man with schizophrenia died from lung abscess with empyema while an involuntary inpatient at a mental health facility. He had been readmitted with a respiratory infection and was treated with intravenous an…
42y · Female·hanging
Holly Thredgold, aged 42, died by hanging on 28 August 2016, less than 40 hours after inappropriate discharge from Royal Adelaide Hospital ED. She presented on 26 August 2016 severely intoxicated with suicidal ideation a…
42y · Female·multiorgan failure complicating hyperthermia and metabolic acidosis following su…
A 42-year-old woman with long-standing depression, substance use issues, and multiple mental health presentations died from multi-organ failure following ingestion of caustic soda. She was found unresponsive at home on 1…
80y · Male·Dehydration and the effects of heat with contributing Alzheimer's dementia
An 80-year-old man with advanced Alzheimer's dementia disappeared from a respite care facility on a day of extreme heat (39°C) and died from dehydration and heat exposure. Key failures included: (1) relocation of the day…
76y · Male·combined effects of acute myocardial infarction and urosepsis
Pasquale Esposito, age 76, died in custody at Lyell McEwin Hospital from combined acute myocardial infarction and urosepsis. He had extensive cardiac history including prior MI, CABG, COPD, and recent stent placement. On…
97y · Male·respiratory failure attributed to aspiration pneumonia on a background of advanc…
Richard Underwood, aged 97, died from respiratory failure due to aspiration pneumonia on a background of advanced dementia, a surgically repaired neck of femur fracture, and gastrointestinal haemorrhage. He was admitted …
20y · Female·multi-organ failure due to polypharmacy overdose
A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where i…
68y · Male·decompensated heart failure with pulmonary hypertensive crisis complicated by pn…
Peter Hohol, a 68-year-old prisoner with significant cardiac comorbidities including ischaemic and dilated cardiomyopathy, died from decompensated heart failure with pulmonary hypertensive crisis complicated by pneumonia…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.