918 results
81y · Male·inanition complicating traumatic brain injury and disseminated malignancy
An 81-year-old man with metastatic bowel cancer suffered a traumatic brain injury from a fall, resulting in multiple intracerebral haemorrhages and cerebral contusions. He was delirious and presented challenging behaviou…
35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…
35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…
86y · Male·multiple injuries from motor vehicle collision
An 86-year-old man died in a head-on motor vehicle collision after driving unsafely on a highway. Three weeks prior, police observed him driving dangerously, unable to judge distances or perceive traffic, and submitted a…
18y · Male·compression of the neck in keeping with hanging
An 18-year-old Aboriginal man died by hanging three days after release from prison on home detention bail. He had been displaying acute psychotic symptoms while in prison custody, placed under camera observation due to s…
36y · Female·head injury
A 36-year-old woman was killed by a young man with early-onset schizophrenia after a chance encounter. The death resulted from a complex series of missed opportunities in mental healthcare management. Key failures includ…
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…
54y · Male·drowning
A 54-year-old man with chronic alcoholism drowned after driving his car into the sea at a boat ramp while extremely intoxicated. After spending several hours drinking with another visitor, he drove his vehicle partially …
33y · Male·hypoxic-ischaemic encephalopathy due to hanging with resuscitation
Matthew Keith Constantine, aged 33, died from hypoxic-ischaemic encephalopathy following a hanging attempt while under home detention. He was released from prison in December 2021 with parole conditions including electro…
64y · Female·acute bronchopneumonia complicating Alzheimer's dementia with head injury
A 64-year-old woman with advanced Alzheimer's dementia died from acute bronchopneumonia following a head injury sustained in an unwitnessed fall. She was under a guardianship order with special powers at the time. Follow…
43y · Male·compression of the neck in keeping with hanging
A 43-year-old man on home detention died by hanging in September 2021. He had a history of epilepsy, depression, anxiety, illicit drug use, and previous suicide attempts. In the weeks before death, he presented to hospit…
32y · Male·Gunshot wound to the head
Mark Bombardieri, a 32-year-old man with a complex history of criminal behaviour, mental health disorders, polysubstance abuse, and multiple psychiatric admissions, died by suicide on 6 March 2019 via self-inflicted guns…
59y · Male·hanging
A 59-year-old man with major depression and psychotic features was lawfully detained under an inpatient treatment order at Noarlunga Hospital's Morier Ward. He was appropriately managed, initially in the high-dependency …
20y · Male·gunshot wound to the chest
A 20-year-old man with borderline personality disorder, who had made over 25 suicide attempts in the two years prior, died from a gunshot wound sustained during a police encounter. He had called mental health services an…
24y · Male·unascertained; likely due to impact with tree or rapid fire following motor vehi…
A 24-year-old man died in a single-vehicle motor vehicle accident after colliding with a tree at high speed while driving erratically. Post-mortem testing revealed high levels of methylamphetamine and cannabis in his blo…
74y · Female·Intracranial haemorrhages (non-operated) on a background of dementia
Frances Veronica Icke, aged 74, died from intracranial haemorrhages on a background of dementia. She fell at home on 31 December 2021 and was admitted to hospital with two brain bleeds. Neurosurgery determined she was no…
22y · Male·neck compression due to hanging
A 22-year-old man with treatment-resistant schizophrenia died by hanging while under guardianship with special powers of detention in supported independent living. He had attempted suicide by drinking bleach one month pr…
61y · Male·ischaemic heart disease with left ventricular hypertrophy
A 61-year-old Aboriginal man died in prison custody from ischaemic heart disease with left ventricular hypertrophy. He had significant cardiac risk factors including type 2 diabetes, hypercholesterolaemia, age, male sex,…
75y · Male·End stage myelodysplastic syndrome and end stage renal failure on a background o…
A 75-year-old man died in prison custody from end-stage myelodysplastic syndrome and renal failure on a background of ischaemic heart disease, hypertension, valvular disease, and metastatic prostate cancer. He was admitt…
71y · Male·ischaemic heart disease due to coronary atherosclerosis
71-year-old man died of ischaemic heart disease due to coronary atherosclerosis while on home detention bail. He had significant cardiovascular risk factors including diabetes, peripheral artery disease, carotid atherosc…
46y · Male·neck compression due to hanging
Matthew Wade Sulley, aged 46, died by hanging while on home detention under Department for Correctional Services supervision. He had a significant psychiatric history including previous suicide attempt by hanging (1997),…
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