24y · Female·Head injury from repeated blunt force trauma
A 24-year-old woman was fatally assaulted by her intimate partner after a period of escalating domestic and family violence. The perpetrator had a documented history of violent DFV across multiple relationships, with pri…
0y · Male·Unascertained in the setting of a remote head injury
…ces over-relied on the young mother (CFT, age 16) as the protective parent despite documented evidence of coercive control and violence. The father's known trauma history and substance abuse required specialist intervent…
49y · Female and male·Gunshot wound to head inflicted by spouse
Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…
31y · Male·Hypoxic encephalopathy caused by neck compression due to hanging
David Wotherspoon, a 31-year-old Aboriginal man with schizophrenia, died from hypoxic encephalopathy following hanging in a prison mental health unit. Despite being psychotic and refusing medication, he was not transferr…
81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…
An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…
48y · Female·Neck compression secondary to hanging
…ng systems abuse—was the key driver. Key lessons include: identify the true perpetrator using patterns of coercive control not incident-based assessment; provide trauma-informed specialist sexual assault support proactiv…
0y · Female·brain death complicating head and neck injury
A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult on at least two occasions: once around 6 May 2019 (evidenced b…
41y · Male·Stab wound to the chest
Jack, a 41-year-old man with extensive history of domestic violence perpetration across multiple relationships, died from a stab wound to the chest inflicted by his partner Sally during a domestic disturbance. Sally had …
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