1,981 results
22y · Male·Hypoxic ischaemic encephalopathy complicating hanging
Christopher Ritson, a 22-year-old with severe alcohol and polysubstance dependence (ICE, cannabis), depression, anxiety and social phobia, died by suicide via hanging on 17 March 2020, four days after discharge from hosp…
74y · Male·metastatic gastro-oesophageal adenocarcinoma
Ivan Milat, aged 74, died of metastatic gastro-oesophageal adenocarcinoma whilst in lawful custody at Long Bay Correctional Centre. He presented with gastrointestinal symptoms from October 2018, was initially treated for…
2y · Male·pneumonia in association with bronchiolitis
Child T, a 2-year-old boy in Department of Communities' care, died from pneumonia in association with bronchiolitis on 13 July 2019. The coroner found the Department should have intervened with more intensive family supp…
43y · Male·Liver failure with cirrhosis in the setting of recent paracentesis and Hepatitis…
Mr Wilson was a 43-year-old Aboriginal man with end-stage liver cirrhosis and hepatitis C who died 18 days after emergency umbilical hernia repair and one day after paracentesis drainage of 8 litres of ascites at a rural…
73y · Female·head injuries suffered in a fall; skull fractures with bruising to the brain and…
A 73-year-old woman with a history of dilated cardiomyopathy and recently inserted pacemaker/defibrillator fell down external restaurant stairs while leaving an anniversary celebration. She tripped or lost balance after …
55y · Male·Complications of pneumonia
David Musicka, a 55-year-old man with cerebral palsy living in residential care, died from complications of pneumonia. Post-mortem examination revealed acute bilateral bronchopneumonia with cavitating lesions and Strepto…
69y · Male·Partial contact range gunshot wound of the head
David Lester Townsend, a 69-year-old man with bipolar disorder and chronic suicidal ideation, died by gunshot wound to the head on 25 September 2017. He had been receiving psychiatric care from Dr McDougall and case mana…
34y · Female·Head injuries from blunt force trauma (multiple blows from axe); abdominal injur…
A 34-year-old pregnant woman died from severe head and abdominal injuries inflicted by her estranged partner in a domestic violence homicide. The death followed escalating domestic and family violence (DFV) including phy…
20y · Male·Hanging
Mitchell Dowling, a 20-year-old university student, died by hanging on 18 July 2018 after a period of psychological treatment for depression with suicidal ideation. He had presented with major depressive disorder with at…
Female·suicide by firearm
A woman in rural Victoria died by suicide using a firearm. She had presented to her GP with depressive symptoms and was referred to mental health services, but there were delays in accessing psychiatric care. The coroner…
70y · Male·carcinoma of the lung
Stuart Dugan, a 70-year-old prisoner with advanced lung cancer, died in hospice care. He had multiple missed opportunities for earlier diagnosis. While smoking-related lung cancer commonly presents late with poor prognos…
89y · Male·multi-organ failure on a background of advanced dementia and small cell lung can…
An 89-year-old prisoner with advanced dementia and small cell lung cancer died from multi-organ failure whilst in lawful custody at Yatala Labour Prison. He entered prison aged 83 with complex medical needs including isc…
75y · Male·cerebral metastatic malignancy (lung cancer with brain metastases)
Kenneth Ballard, aged 75, died in prison custody from cerebral metastatic lung cancer. He had been diagnosed with chronic lymphocytic lymphoma in 2012 and managed at Mount Gambier Prison. In late 2014, Mr Ballard refused…
56y · Male·aspiration pneumonitis secondary to airways obstruction from squamous cell carci…
Edgar Forrester, a 56-year-old Aboriginal man, died of aspiration pneumonitis secondary to oesophageal squamous cell carcinoma with metastases while in custody. He presented with progressive dysphagia from September 2019…
61y · Male·end stage renal failure, in the context of type 2 diabetes mellitus and chronic …
Robert Curtis, a 61-year-old Aboriginal man with end-stage renal disease, end-stage liver disease, and poorly controlled diabetes, was imprisoned for driving while disqualified on 4 February 2019. He fell in the prison s…
36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)
A 36-year-old motor mechanic with chronic pain from a 2014 knee injury died from combined drug toxicity (pregabalin, morphine, amitriptyline). His general practitioner, Dr S., prescribed excessive amounts of multiple med…
47y · Male·Hanging
A 47-year-old man with newly diagnosed schizophrenia died by hanging. He had presented with paranoid delusions and was engaged with mental health services in February 2017. Critical deficiencies were identified in the me…
29y · Female·Mixed drug toxicity (gamma hydroxybutyrate, methylamphetamine, amphetamine, diaz…
A 29-year-old woman with a history of childhood and intimate partner violence died from mixed drug toxicity (GHB, methylamphetamine, amphetamine, diazepam). She had multiple mental health diagnoses including PTSD, depres…
17y · Female·Complications of acute asthma in the setting of an allergic response
Catherin D'Rozario, 17 years old, died from complications of acute asthma triggered by anaphylaxis after consuming food containing sesame at a restaurant on 25 August 2019. Despite known allergies to nuts, sesame, fish a…
35y · Male·Hanging
Brett McDonnell, a 36-year-old man, died by hanging in January 2018 while subject to a Community Corrections Order and facing pending criminal charges. He had a history of depression treated with Pristiq since 2015, but …
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