873 results
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm
Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…
48y · Male·Complications of human immunodeficiency virus infection with terminal palliative…
Travis Dion Baumgarten was a 48-year-old Aboriginal man serving a prison sentence at Acacia Prison in Western Australia who died on 5 December 2022 from complications of untreated HIV/AIDS. After HIV diagnosis in 1994, h…
45y · Male·atherosclerotic heart disease
Lex Gregory Maher, a 45-year-old Aboriginal man imprisoned at Greenough Regional Prison, died of atherosclerotic heart disease while playing basketball. He had abnormal ECGs detected in March and May 2022 and was appropr…
22y · Male·ligature compression of the neck (hanging)
Ricky-Lee Cound, 22, an Aboriginal man with FASD, died by hanging in his Hakea Prison cell on 25 March 2022. At 4.11pm, Mr Cound called requesting a monitored safe cell to prevent self-harm, demonstrating clear risk perc…
23y · Male·Multiple injuries from being struck by train
Jalen Hunter Norris, aged 23, died by suicide when struck by a train on 9 April 2021. He was experiencing paranoid delusions and had recently been arrested for criminal damage and cannabis possession after an incident at…
51y · Male·complications of myocardial infarction in association with ischaemic heart disea…
A 51-year-old Aboriginal male prisoner with multiple cardiovascular risk factors (diabetes, hypertension, high cholesterol, chronic kidney disease, obesity, smoking) died on 5 February 2024 from myocardial infarction. He…
8y · Female·Multiple injuries
Bubba E, an 8-year-old child in Department of Communities out-of-home care, died from multiple injuries when she was ejected from a motor vehicle that rolled after the driver took evasive action to avoid colliding with a…
64y · Male·complications in association with thermal injuries in a man with underlying chro…
Kim Vulich, a 64-year-old man with decompensated liver cirrhosis from chronic alcohol use, developed hepatic encephalopathy and cognitive impairment including possible Korsakoff syndrome. Despite SAT guardianship orders …
17y · Male·Nathan: head injury; Jesse: multiple injuries
Two young men—Nathan Randall (17) and Jesse Kyel Dixon (22)—died when Nathan's unlicensed motorcycle collided with trees near East Rockingham on 18 August 2022 at approximately 2.10 am. Nathan was intoxicated by alcohol …
Nathan: head injury from motorcycle collision with trees; Jesse: multiple injuri…
Two young men, Nathan Randall (17) and Jesse Dixon (22), died when their motorcycle collided with trees in East Rockingham, Western Australia. Nathan was riding without a valid motorcycle license while intoxicated (canna…
47y · Male·Unascertained - likely accidental drowning while trapped on reef (injury from re…
Aaron Beveridge, a 47-year-old experienced surfer, disappeared while surfing at Surfers Point, Prevelly on 7 June 2024. He became trapped on a reef when his surfboard's leg rope caught on a rock formation known locally a…
38y · Male·electrical injury
Benjamin Van Trigt, a 38-year-old man with schizoaffective disorder, died by electrocution at home on 17 November 2022 while on a Community Treatment Order (CTO). He had experienced multiple psychiatric relapses requirin…
28y · Male·drowning
Muh Tuu Jeng, a 28-year-old Taiwanese fisherman, disappeared from a fishing vessel approximately 40 nautical miles off Broome, Western Australia on 7 September 1988. He and another crew member fell overboard in rough sea…
41y · Male·Unascertained - may have resulted from injuries sustained in fall from vessel or…
Tanghui Huang, a 41-year-old Chinese able seaman, disappeared from a bulk carrier vessel off Dampier, Western Australia on 21 April 2012. He was last seen painting the mooring winch at 11:30 am and was presumed to have f…
59y · Male·ligature compression of the neck (hanging)
Christopher Hillstead, a 59-year-old prisoner serving a life sentence for wilful murder, died by suicide by hanging on 18 January 2021 at Acacia Prison, Western Australia. He had been pursuing tertiary education (master'…
55y · Male·Complications of liver cirrhosis and hepatocellular carcinoma in a man with mult…
Robert Exell, a 55-year-old Aboriginal man, died from complications of liver cirrhosis and hepatocellular carcinoma while in custody. He had chronic hepatitis C and alcohol-related liver disease since at least 2012. Key …
50y · Male·ligature compression of the neck (hanging)
Matthew Francis Leach, a 50-year-old man with longstanding alcohol dependence, depression, and a history of suicide attempts, died by ligature hanging in his cell at Hakea Prison shortly after being sentenced to 12 month…
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
22y · Male·Immersion in water (drowning) in a man with combined drug effect
Jaxon Charles Kinnane, 22, drowned in the Swan River on 12 October 2020. He had chronic schizophrenia with persistent delusional beliefs (microchip in ear) and was a polysubstance user, particularly methylamphetamine. He…
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