33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes
A 33-year-old man with major depressive disorder and multiple suicide attempts died by carbon monoxide poisoning after premature discharge from psychiatric inpatient care. He was admitted to Lyell McEwin Health Service o…
36y · Male·Cardiac failure associated with intravenous methylamphetamine abuse and exertion
A 36-year-old man died from cardiac failure associated with intravenous methylamphetamine abuse and exertion. He had injected methylamphetamine and subsequently engaged in intense physical activity (running, climbing fen…
29y · Male·hanging
A 29-year-old man remanded in custody at Adelaide Remand Centre died by hanging on 15 January 2000. At admission, he denied self-harm risk and psychiatric history; no warning signs were identified. He was found hanging f…
58y · Male·hanging
A 58-year-old man remanded in custody awaiting trial died by hanging in prison. He had a history of depression treated with fluoxetine and was assessed by a forensic psychiatrist who found no evidence of depression or su…
37y · Female·blunt head trauma with skull fractures
Renee Frodsham, aged 37, disappeared on 17 March 1980 near Whyalla, South Australia. Her remains were discovered in April 1997 at Sinclairs Gap following information provided by Jacqueline Abbott regarding confessions ma…
45y · Female·haemorrhage due to traumatic rupture of the liver
A 45-year-old woman with a long history of bipolar disorder and personality disorder presented to the ED at 2:30 AM after cutting her wrist deeply with a carving knife. The treating casualty officer did not properly docu…
15y · Male·salt water drowning
Damian Alan Benson, aged 15, died by salt water drowning in the Southern Ocean near Carpenter Rocks, South Australia on 26 July 1998 during a fishing trip with his father. They departed in a 25-30 year old dinghy with a …
26y · Male·respiratory arrest complicating hydrocarbon inhalation (sudden sniffing death)
A 26-year-old man with schizophrenia, antisocial personality disorder, and polysubstance abuse died from sudden sniffing death syndrome after inhaling fly spray in a psychiatric ward smoking room. Three days prior, staff…
18y · Female·hypoxic encephalopathy due to raised intracranial pressure caused by severe clos…
An 18-year-old woman died from hypoxic encephalopathy due to severe closed head injury sustained when she fell from a shade sail structure at a playground. While climbing on the sail with friends after consuming minimal …
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. …
26y · Male·Closed head injury with extradural and subdural haemorrhage resulting from a sku…
26-year-old Marcio Jose Lay Nheu died from a closed head injury with extradural haemorrhage caused by a blow to the head with a Maglite torch at Karama Shopping Centre. He was struck by Rodney Foster during an altercatio…
25y · Male·positional asphyxia in a man with extensive old hypoxic brain damage, acute ches…
Corey Paddy, a 25-year-old Aboriginal man with severe hypoxic brain injury from a 1998 car accident, died at Katherine Hospital from positional asphyxia while receiving concurrent morphine therapy and suffering from acut…
1y · Male·neck compression due to hanging from curtain cord
A 15-month-old boy died from neck compression caused by entanglement in a curtain cord while sleeping in his cot. The cord, used to close nearby curtains, became wrapped around his neck despite the mother's belief it had…
81y · Female·respiratory arrest caused by bronchopneumonia contributed to by non-Hodgkin's ly…
An 81-year-old woman with dementia and non-Hodgkin's lymphoma died of respiratory arrest caused by bronchopneumonia while detained at a mental health facility. She was admitted to Glenside Hospital in November 1999 and t…
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…
62y · Female·ventricular fibrillation associated with congestive cardiomyopathy
A 62-year-old woman detained under the Mental Health Act for acute psychiatric deterioration (psychosis, confusion, paranoia) secondary to anxiety following cardiomyopathy diagnosis died from ventricular fibrillation ass…
37y · Male·Sergeant Huitson: gunshot wound to chest and abdomen; Ansell: multiple gunshot w…
This coronial inquiry examined a shooting incident on 3 August 1999 where Rodney Ansell, a man suffering from deteriorating mental health and chronic amphetamine abuse, opened fire on the Stuart Highway killing Sergeant …
26y · Male·.357 magnum gunshot wounds to the chest and abdomen
Luke Donaghey, a 26-year-old man with untreated psychotic illness, was shot by police after threatening his parents with a knife. Critical clinical lesson: his general practitioner failed to utilize available mental heal…
Unknown·Multiple injuries sustained after being struck by a white Mitsubishi Triton util…
On 12 July 1998, Anthony Malcolm Mahoney (56) and Jane Stuart Mahoney (43), a married couple, were struck by a white Mitsubishi Triton utility vehicle while changing a tyre on Cox Peninsula Road, Northern Territory. Both…
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 …
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