918 results
76y · Female·lower limb ischaemia due to diabetes and peripheral vascular disease
Elizabeth Mathilda Blake, aged 76, died at Marten Residential Care Centre from lower limb ischaemia secondary to diabetes and peripheral vascular disease. She had long-standing psychiatric illness progressing to dementia…
37y · Male·dehydration/heat-related death
A 37-year-old man died from dehydration and heat-related illness after collapsing in a sweat lodge during a vision quest ceremony in remote South Australia. He remained unconscious after removal from the lodge, but the g…
24y · Male·blunt force chest trauma
Martin John Philp, 24 years old, died from blunt force chest trauma following a high-speed motorcycle collision on Port Road, Cheltenham. He was riding a 600cc Honda motorcycle (exceeding his licence restriction of 250cc…
53y · Male·asphyxia from combined effects of neck compression from hanging and suffocation …
John Trenorden died by suicide in prison following his arrest for allegedly murdering his former business partner Penelope Christopher. Police correctly identified him as at-risk after he attempted to step in front of tr…
84y · Male·lower respiratory tract infection complicating congestive cardiac failure
Harold Leslie McInerney, 84, died from lower respiratory tract infection complicating congestive cardiac failure while detained under the Mental Health Act at Queen Elizabeth Hospital. He was admitted for bleeding ulcers…
37y · Male·hypoxic ischaemic encephalopathy secondary to hanging
A 37-year-old man with depression, suicidal ideation, and antisocial personality disorder died from hypoxic ischaemic encephalopathy following hanging while on home detention bail. He had been arrested following a domest…
44y · Male·multiple injuries sustained when struck by a semi-trailer as a result of suicide
A 44-year-old man with chronic bipolar disorder and severe depression died by suicide while detained under the Mental Health Act at a psychiatric hospital. He was hit by a semi-trailer after absconding from an open ward.…
51y · Male·Hanging
Stephen Cartwright, a 51-year-old psychologist, was arrested for breach of bail and died by hanging in police custody at Christies Beach Police Station. He displayed multiple risk factors including depression requiring m…
16y · Female·intra-abdominal haemorrhage due to ruptured spleen
A 16-year-old girl died from intra-abdominal haemorrhage due to ruptured spleen following a car rollover. She was transported by ambulance to the nearest hospital (Renmark) rather than the better-equipped Berri Hospital,…
38y · Male·ischaemic heart disease due to severe coronary atherosclerosis
Stuart Murray Chalklen, aged 38, died in Adelaide Remand Centre from ischaemic heart disease due to severe coronary atherosclerosis. He complained of left shoulder pain (a recognised symptom of cardiac disease) to cellma…
82y · Female·multi organ failure from burns on a background of aortic stenosis and ischaemic …
An 82-year-old woman with chronic pain from osteoporosis used a hot water bottle at a nursing home. A carer filled it with boiling water directly from a kettle and positioned it against the patient's back without followi…
23y · Female·drowning and citalopram overdose
23-year-old woman with major depressive disorder presented to multiple healthcare providers on 17 March 2004 with suicidal ideation. She was referred to Flinders Medical Centre Emergency Department by her GP, where she w…
36y · Male·Multi-organ failure due to consequences of multiple injuries sustained following…
A 36-year-old man with chronic treatment-refractory paranoid schizophrenia was involuntarily detained in an acute psychiatric ward after a failed community trial. Despite being a documented high absconding risk, he was t…
30y · Female·bronchopneumonia complicating anoxic encephalopathy due to neck compression due …
Julia Marie Baylis, a 30-year-old woman, died from bronchopneumonia complicating anoxic encephalopathy due to hanging after being placed in custody at Elizabeth Police Station. Critical failures in prisoner supervision a…
79y · Male·myocardial infarction
A 79-year-old man with significant comorbidities (ischaemic heart disease, diabetes, peripheral vascular disease) was admitted to hospital with anorexia and weight loss. He developed acute confusion and delirium, initial…
Multiple stab wounds to chest (David Gerard: stab wound to chest piercing heart;…
Joint inquest into two homicides by individuals with schizophrenia who were managed by mental health services. Anthony Butler stabbed David Gerard in 2001 after being discharged from Glenside Hospital without Community T…
83y · Female·Drowning, likely associated with cardiac arrhythmia or tidal conditions, or a co…
Skaidrite Dreiman, 83, disappeared while swimming at Brighton Beach on 17 November 2003 and is presumed dead by drowning. She had a significant cardiac history including atrial fibrillation managed with medications, a mi…
51y · Male·ischaemic heart disease
A 51-year-old prisoner died from ischaemic heart disease after suffering a cardiac event while being transferred between prison units. He had complained of chest pain to correctional officers, was directed to walk to the…
27y · Male·Airway obstruction due to sublingual and submandibular cellulitis (Ludwig's angi…
A 27-year-old man died from airway obstruction due to Ludwig's angina (bilateral sublingual and submandibular cellulitis) following a tooth extraction. Critical failures included: delayed treatment with inadequate timely…
20y · Female·Cerebral anoxia consequent upon a severe acute asthmatic event
Sally Anne Gordon, a 20-year-old with a 14-year history of severe brittle asthma, presented to Mount Gambier Hospital on 26 November 2000 with acute severe asthma unresponsive to initial treatment. After appropriate emer…
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