756 results
31y · Male·coronary occlusion contributed to by atheroma
David John Pendergast, a 31-year-old Aboriginal Australian prisoner at Alice Springs Correctional Centre, died from coronary occlusion contributed to by severe atheroma on 10 June 2001. He suffered a massive cardiac arre…
15y · Male·compression of the neck by hanging
A 15-year-old Aboriginal male, Johnno Wurramarrba, from Groote Eylandt died by hanging in Don Dale Juvenile Detention Centre on 10 February 2000, while serving a 28-day sentence for property offences. Key preventable fac…
67y · Female·bronchopneumonia complicating disseminated pulmonary large cell carcinoma with r…
Nancy McCarthy, 67, presented with progressive back and chest pain initially attributed to vertebral compression fracture. She deteriorated acutely with confusion, agitation, and respiratory distress, necessitating Menta…
64y · Female·Haemorrhagic bronchopneumonia complicating doxepin overdosage
A 64-year-old woman died from doxepin overdose complicated by haemorrhagic bronchopneumonia. She had attempted suicide in April 1999 and was referred to a psychiatrist (Professor Schioldann) who prescribed sertraline. He…
Unknown·Unknown for majority of cases; one case (Marrakai Plains, circa 1976) determined…
This consolidated inquest concerned 15 sets of unidentified skeletal remains discovered at various remote and rural locations across the Northern Territory, including Cartier Island, Marrakai Plains, Malay Bay, Katherine…
74y · Male·disseminated carcinoma (widespread cancer); specifically haemorrhage into right …
Ronald Smallwood, a 74-year-old man with chronic paranoid schizophrenia and renal cancer, died in hospital from disseminated carcinoma. The key clinical lesson relates to institutional knowledge rather than direct patien…
69y · Female·Respiratory obstruction by aspirated food (Brussels sprout, chicken and carrots)…
Helena Czekajlo, aged 69, died from respiratory obstruction by aspirated food (Brussels sprout) at a nursing home. She had dementia and schizophrenia with a documented obsession about food and tendency to eat hurriedly. …
68y · Female·glottic obstruction by food bolus
A 68-year-old woman with Huntington's disease, schizophrenia, and schizoaffective disorder died from glottic obstruction by food bolus while eating breakfast in a psychiatric hospital where she was detained under the Men…
28y · Male·asphyxiation following severe swelling to the larynx due to anaphylactoid reacti…
A 28-year-old Aboriginal male died from anaphylactoid reaction to Haemaccel, a plasma volume expander administered pre-hospital following a severe laceration to the radial artery. Initial management was appropriate, but …
27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…
A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…
29y · Male·left cerebrovascular accident (stroke) due to thromboembolism in the middle cere…
A 29-year-old male bodybuilder died from left cerebrovascular accident (stroke) caused by thromboembolism. He had a history of anabolic steroid use and presented after a minor motor vehicle accident on 6 April 1999. Imag…
84y · Male·severe head injuries (fracture of skull on right side, subarachnoid haemorrhage,…
An 84-year-old man with severe respiratory disease, cardiac failure, poor vision and confusion fell from a first-floor hospital window, sustaining fatal head injuries. The coroner found the death was not deliberately sel…
<1y · Female·premature delivery; extreme prematurity
A 19-week pregnant woman was admitted for pregnancy termination due to maternal psychological concerns. Labour was induced with misoprostol, expecting foetal death in utero or delivery of non-viable remains. Instead, a l…
3y · Male·smothering
A 3-year-old boy died from smothering by his mother, who was suffering from severe bipolar affective disorder with psychotic features and severe depression. The coroner examined whether psychiatric care was inadequate. T…
23y · Male·aspiration of blood due to stab wound to trachea
23-year-old man with self-inflicted stab wound to neck presenting to emergency department while intoxicated and agitated. Ambulance noted 3cm laceration to midline trachea with minimal external bleeding. Registered nurse…
<1y · Female·unknown
This coronial finding concerns the death of Azaria Chamberlain, a 9-week-old infant who disappeared from a tent at Ayers Rock on 17 August 1980. After her parents were convicted of murder and accessory after the fact (la…
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