918 results
23y · Male·injuries sustained in a shark attack
A 23-year-old research assistant died from injuries sustained in a Great White shark attack while conducting a University of Adelaide diving expedition in the Gulf of St Vincent. The inquest examined whether risk assessm…
0y · Female·undetermined; possible suffocation not definitively established at autopsy
A 4-week-old neonate died at home with undetermined cause, though suffocation on a soft pillow was considered possible. The infant was born prematurely on a concrete pavement to a mother with untreated opioid addiction a…
71y · Female·undetermined
71-year-old woman found dead in unusual position at Brighton aged care facility. Her body was positioned with head resting against bed pole, with marks on neck and bruising observed by carers. The death was certified as …
18y · Male·methadone toxicity
Thomas Ryan Keough, aged 18, died from methadone toxicity at Palm Lodge, a supported residential facility for people with mental illness, in August 2003. His body was not discovered for 48 hours after death. The coroner …
17y · Female·raised intracranial pressure due to hepatic encephalopathy related cerebral oede…
Jacqueline Wood, aged 17, died from hepatic encephalopathy-related cerebral oedema following fulminant liver failure caused by paracetamol overdose. She ingested approximately 90 paracetamol tablets on 3 June 2002 but di…
54y · Male·Deaths from bushfire (incineration, inhalation of products of combustion, blunt …
A major bushfire on the Lower Eyre Peninsula in South Australia on 10-11 January 2005 killed nine people. The fire originated from a carbonaceous particle emitted from Marco Visic's diesel vehicle exhaust system with def…
84y · Female·ischaemic heart disease
An 84-year-old woman with dehydration, fever, and confusion initially refused hospital admission due to fears of nursing home placement. Her GP appropriately obtained a Mental Health Act detention order when she refused …
22y · Male·cerebral trauma associated with skull fractures
A 22-year-old male died from cerebral trauma and skull fractures after colliding with a soccer goalpost while riding an unregistered, unlit motorcycle without a helmet across a dark reserve. The collision occurred during…
30y · Male·exposure
A 30-year-old man died from exposure in a remote wilderness area after abandoning his vehicle on a difficult four-wheel-drive track. His vehicle became stuck on a slope; despite having adequate water, food, and fuel, he …
50y · Female·mixed tablet overdosage (quetiapine and venlafaxine with codeine)
Treenor Heather Randall, a 50-year-old registered nurse, died from mixed tablet overdose (quetiapine and venlafaxine) following a progressive mental health decline. After work-related stress in late 2002, she developed d…
37y · Male·Hanging
Robert Allen Johnson, aged 37, died by hanging in his prison cell at Yatala Labour Prison on 21 September 2005. He had been remanded in custody the previous day on serious charges. Upon admission, he was initially assess…
0y · Female·combined effects of asphyxia and inhalation of gastric contents
Elizabeth Rose Edwards, a 9-month-old premature infant with perinatal brain injury, died of asphyxia and aspiration of gastric contents while in temporary foster care. She had been placed with carers (the Todds) with min…
30y · Male·hanging
Arthur Smith, a 30-year-old man remanded in custody, died by hanging in Yatala Labour Prison on 13 January 2005. He had a complex psychiatric history including borderline personality disorder, chronic depression, polysub…
63y · Male·uncontrolled haemorrhage from ruptured aortic aneurysm
A 63-year-old man presented with sudden back pain on 6 March 2004. Ambulance officers attended twice; on the first visit they did not transport him to hospital despite his request, misattributing his symptoms to musculos…
44y · Male·Sepsis and pulmonary thromboemboli complicating a ruptured cerebral artery aneur…
Peter Gillam, age 44, died from sepsis and pulmonary thromboemboli complicating a ruptured cerebral aneurysm with subarachnoid haemorrhage (SAH). On 16 December 2004, his GP Dr H. referred him urgently for CT head to exc…
95y · Female·asphyxia due to glottic obstruction by food
A 95-year-old female with advanced dementia died from asphyxia caused by food impaction in the glottis. She was prescribed a soft diet (soft vegetables, vitamised meat) but was served and fed a meal containing large unco…
24y · Male·diffuse hypoxic ischaemic encephalopathy due to hanging
Colin Craig Sansbury, 24-year-old Aboriginal man, died by hanging while in police custody at Elizabeth Police Station. Critical failures in care included: (1) Inadequate psychiatric assessment at Lyell McEwin Hospital—he…
Female·hypoxic-ischaemic encephalopathy due to intrapartum hypoxia due to delayed deliv…
A 54-hour-old neonate died of hypoxic-ischaemic encephalopathy following a planned home birth of twins. The second twin experienced a prolonged delay in delivery (over 60 minutes) during which foetal heart rate decelerat…
58y · Male·Hypoxic encephalopathy secondary to cardiac arrest due to cardiomegaly
Robert John Viner, a 58-year-old man with long-standing schizoaffective disorder, was detained under the Mental Health Act on 28 July 2006 following erratic behaviour and aggression towards family and his GP. He was admi…
40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)
Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anae…
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