1,981 results
64y · Male·Hypostatic bronchopneumonia complicating end stage Parkinson's disease
Gary Edward Holmes, 64, died from hypostatic bronchopneumonia complicating end-stage Parkinson's disease while receiving palliative care at Colac Hospital. He was a profoundly disabled man (deaf and blind from childhood)…
57y · Female·Head and chest injuries due to motor vehicle collision (driver)
A 57-year-old woman with insulin-dependent diabetes died in a motor vehicle collision caused by hypoglycaemia while driving. Her insulin pump data showed 16 hypoglycaemic events in the preceding month, with multiple epis…
70y · Male·Hanging
A 60-year-old man with recent pituitary surgery developed persistent fatigue and depressive symptoms. Despite normal cortisol levels, he remained convinced his symptoms were due to hormonal deficiency rather than depress…
44y · Male·Gunshot wound to the head
Jason Smith, 44, was shot in the head by his uncle John Pozzebon in a family violence incident. The coroner found that while Pozzebon had a valid firearms license, his mental health had deteriorated significantly followi…
32y · Male·Aspiration pneumonia and reflux oesophagitis
Timothy Luke Rubenach, aged 32, died of aspiration pneumonia following severe reflux oesophagitis. He had profound intellectual disability and drug-resistant epilepsy from meningococcal infection at 5 months. His parents…
75y · Female·Haemopericardium due to dissection of the ascending aorta
A 75-year-old woman died from haemopericardium due to ascending aortic dissection. She presented to her GP on 20 February 2020 with central chest pain radiating to the jaw, which the GP attributed to possible acute myoca…
40y · Female·Cerebral oedema of unknown aetiology with probable contribution from Hashimoto's…
Sarah Louise Rose, aged 40, died from cerebral oedema of unknown aetiology with probable contribution from Hashimoto's encephalopathy. She had been diagnosed with Hashimoto's thyroiditis in late 2011 and prescribed thyro…
53y · Male·Complications of old brain injury in prior motor vehicle incident
Bruce Vernon Taylor, 53, died from complications of a remote brain injury sustained in childhood motor vehicle accident. He lived in shared disability accommodation and received support through NDIS. In the 12 months bef…
47y · Male·sequelae of ruptured brain aneurysm
John Laurenson, a 47-year-old remand prisoner, died from rupture of a brain aneurysm on 20 June 2017, four days after collapsing in his prison cell. He had multiple intracranial aneurysms identified in 2015-2016, includi…
32y · Male·unascertained; most likely exposure after walking in bushland
Jason Marcus Lawson, a 32-year-old man with a complex psychiatric history including depression, anxiety, polysubstance use, and previous suicide attempts, disappeared on 11 December 2003, one week after discharge from an…
35y · Female·multiple injuries sustained in fall from sixth-floor balcony
FJ, an Iranian woman with bipolar affective disorder and schizophrenia, died by suicide at age 35 in November 2016. Key clinical lessons include: (1) the critical importance of continuity of psychiatric care during trans…
36y · Female·combined effects of baclofen toxicity and blunt head injury
Kim Melissa Hall, 36, died from combined baclofen toxicity and blunt head injury sustained during falls while acutely intoxicated. She had severe alcohol dependence treated with off-label baclofen prescribed by her GP. O…
61y · Male·Hanging
Stanley Bruce Weaver, a 61-year-old firefighter with a history of depression and previous suicide attempts, died by hanging at his workplace on 26 August 2019. His wife had reported concerns about medication stockpiling …
36y · Male·bronchial asthma
Nathan Reynolds, a 36-year-old Aboriginal man with severe asthma, died from bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease man…
35y · Female·Stab wounds to the chest
Chan Chen, 35, was killed by her husband Andrew Luo in their home through stab wounds to the chest. Luo had displayed increasingly erratic behaviour throughout 2019, including delusions of persecution, beliefs that Chen …
65y · Male·Complications of end stage renal failure in a man with multiple co-morbidities
Mr Kermond, a 65-year-old man with intellectual disability, visual and hearing impairment living in a group home, was admitted to Lyndoch Living for respite care on 25 July 2019. He had end-stage renal failure and multip…
24y · Male·Gunshot wound to the head
A 24-year-old man with bipolar disorder and ADHD died by gunshot wound to the head approximately 5 months after a serious suicide attempt by overdose. He had been assessed as fit to hold a firearms licence by his treatin…
62y · Female·Gunshot wounds to the head
Rosemary Gibson, age 62, was fatally shot by her husband Alan Gibson on 14 April 2016 in their Traralgon home. The death occurred in the context of family violence, with multiple risk factors present: the perpetrator had…
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…
29y · Male·Combined drug toxicity (pregabalin, dihydrocodeine, tramadol, temazepam, lorazep…
A 29-year-old man with class III obesity died from combined drug toxicity involving pregabalin, dihydrocodeine, tramadol, temazepam, and lorazepam. He engaged in prescription medication abuse over 12 months, consulting a…
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