138 results
66y · Male·Ruptured abdominal aortic aneurysm
A 66-year-old man presented to the Emergency Department with left-sided abdominal pain on 14 July 2021. After waiting over 6 hours in a crowded ED with restricted access to treatment spaces, he left without medical asses…
32y · Male·Mixed drug toxicity
A 32-year-old man with bipolar disorder and substance abuse history died from mixed drug toxicity (oxycodone 0.7 mg/L, tramadol, benzodiazepines, cannabis and amphetamines). Emergency services attended after his partner …
72y · Male·Choking on a food bolus
A 72-year-old man with vascular dementia, stroke history, and dysphagia died from choking on food while being fed by a nurse in aged care. The coroner found the death was preventable due to staff lack of training in safe…
36y · Male·Multiple Sharp Force Injuries to Chest and Neck
Mr J, a 36-year-old with a history of first-episode psychosis (2012) and relapse (2014) both associated with methamphetamine use, ceased antipsychotic medication in September 2019 with GP support after achieving 3 years …
44y · Male·Stab wound to the chest
Marcus Lloyd Adams, a 44-year-old man, died from a stab wound to the chest inflicted by his de facto partner during a physical altercation at a caravan park on 20 September 2019. There was no prior history of family viol…
49y · Male·Complications of a right superficial femoral artery injury (operated) following …
A 49-year-old man died from complications of a right superficial femoral artery injury sustained when he was struck by a circular saw at a landscaping worksite. Despite receiving immediate first aid, emergency transport …
43y · Female·choking on a food bolus
Joanne Callahan, a 43-year-old woman with intellectual disability and autism, died from choking on a food bolus while attending a disability day program. Critical failures in communication between her residential care pr…
25y · Male·Hypoxic ischaemic brain injury due to hanging
Dylan Charlton-Smith, aged 25, died by hanging while in custody at Fulham Correctional Facility. A stressful visit from his partner preceded his death by approximately 50 minutes. A correctional officer identified distre…
30y · Male·Complications of methylamphetamine toxicity
Matthew Dongelmans, aged 30, died from complications of methylamphetamine toxicity after being arrested for breaching a family violence intervention order. He consumed methylamphetamine prior to arrest, likely in panic w…
50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…
A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleedin…
48y · Male·Ischaemic heart disease complicating restraint of an acutely agitated male
Daniel Richards, 48, died from ischaemic heart disease precipitated by restraint during a mental health assessment at home. He had underlying significant coronary artery disease with left ventricular hypertrophy and old …
47y · Male·Pneumonia (1(a)), Motor neurone disease (1(b))
Raymond Cassar, a 47-year-old man with motor neurone disease requiring ventilatory support, died of pneumonia at a disability accommodation service. He had been diagnosed with a chest infection on 19 June 2018 and prescr…
42y · Female·Traumatic right subdural haematoma
A 42-year-old woman died from a traumatic right subdural haematoma sustained on 22 January 2015. She was found unresponsive at home with severe head and facial injuries after falls. Critical delays in medical assessment …
35y · Male·unascertained - multifactorial: underlying ischaemic heart disease, drug intoxic…
David Perry, aged 35, died from unascertained causes during police arrest at Bellbrae on 11 January 2019. He presented to The Alfred with acute paranoia, hallucinations and agitation following synthetic cannabis use, and…
44y · Female·haemoperitoneum due to ruptured splenic subcapsular haematoma in the setting of …
Kylie Cay, a 44-year-old woman, was brutally assaulted by her partner Justin Turner on 18 June 2016, sustaining rib fractures and other injuries. She was discharged from hospital on 20 June after imaging did not reveal a…
45y · Male·coronary artery disease and mechanical asphyxia in a man using cocaine
A 45-year-old man with a history of drug-induced psychosis, cocaine use, and underlying coronary artery disease died in police custody following physical restraint at a licensed bar. After consuming cocaine, he experienc…
30y · Male·Mixed drug toxicity (4-Fluoroamphetamine, 25C-NBOMe, dimethylamphetamine, methyl…
Jason, aged 30, died from mixed drug toxicity after ingesting what he believed to be MDMA but which actually contained 25C-NBOMe and 4-fluoroamphetamine, combined with GHB. He experienced seizures and collapsed; CPR was …
32y · Male·Mixed drug toxicity (25C-NBOMe, 4-fluoroamphetamine, doxylamine)
A 32-year-old man died from mixed drug toxicity after consuming tablets he believed were MDMA, which actually contained 25C-NBOMe and 4-fluoroamphetamine—novel psychoactive substances (NPS) of unknown potency obtained fr…
39y · Male·Choking on a food bolus
Mark Capovilla, a 39-year-old man with severe intellectual disability, epilepsy, and dysphagia, died from choking on food at his day program. He had a documented choking risk but lacked a current mealtime support plan at…
76y · Female·Ludwig's angina
A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognis…
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