29y · Female·asphyxiation due to ligature compression of the neck (hanging)
Wendy Anne Eadie, 29, died by suicide in Graylands Hospital's Frankland Centre on 1 November 1998 while detained following charges of unlawful wounding against her parents. She had a longstanding history of depression, c…
41y · Male·closed chest injuries (ruptured hemi-diaphragm with displacement of abdominal co…
Trevor Coppins, a 41-year-old plant operator, died from closed chest injuries sustained when a road roller he was operating failed to brake while reversing down a steep hill and overturned. Investigation revealed the bra…
17y · Female·Neck injury sustained when struck by a motor vehicle (Toyota Celica Hatch Regist…
Emma Anne Motteram, aged 17, died from a neck injury sustained when struck by a motor vehicle on Roe Highway, High Wycombe, Western Australia on 22 March 1998. She had been walking with four companions on the central med…
27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…
A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…
76y · Male·pneumonia
A 76-year-old man with dementia, detained under the Mental Health Act at Glenside Hospital, died of pneumonia. He had multiple comorbidities including congestive cardiac failure and irregular pulse. On 3 November, his pn…
82y · Male·Lateral left ventricular myocardial infarction attributed to severe left circumf…
An 82-year-old man with severe chronic obstructive airways disease and dementia died of acute myocardial infarction while detained under mental health legislation in a secure psychiatric ward. He had been given clonazepa…
43y · Female·sepsis secondary to extensive acute peritonitis following perforation of small b…
43-year-old woman died from sepsis and necrotising fasciitis following small bowel perforation during laparoscopic tubal ligation. She was at high risk due to previous abdominal surgeries and adhesions. A 4-5mm perforati…
77y · Female·myocardial infarction
Eileen Sarah Elliott, aged 77, died of myocardial infarction following a fall and leg fracture in January 2000. She was admitted to Glenside Hospital under a Mental Health Act detention order for chronic schizophrenia. A…
39y · Female·neck compression due to hanging
A 39-year-old woman with bipolar disorder, depression, substance abuse (alcohol and cannabis), and multiple past suicide attempts died by hanging at home on 11 February 1998. She had been discharged from psychiatric hosp…
37y · Male·Multiple injuries including lung lacerations and contusions, multiple rib fractu…
Andrew Grant Baulderstone, aged 37, died from multiple injuries when refractory material collapsed from the lining of a pellet kiln at BHP's Whyalla plant while he was jackhammering. The collapse resulted from failures i…
Unknown·Traumatic injuries caused by the collapse of the Alpine Way fill embankment trig…
On 30 July 1997, a landslide at Thredbo Village killed 18 of 19 people in two lodges. The Alpine Way embankment, constructed in the 1950s as a temporary construction road, was marginally stable and had a history of lands…
26y · Male·neck compression due to hanging
A 26-year-old Aboriginal man with longstanding borderline personality disorder, substance abuse, and multiple suicide attempts died by hanging in a psychiatric ward whilst detained under a Mental Health Act order. Key cl…
30y · Male·cardiac arrhythmia due to therapeutic clozapine use
Edmund James Fern, aged 30, died at a psychiatric institution (James Nash House) on 4 September 1997, nine days after septoplasty for nasal obstruction. He was on multiple medications including clozapine 350mg nightly, c…
38y · Male·neck compression due to hanging
Michael Andrew Curren, a 38-year-old prisoner at Mobilong Prison, died by hanging on 10 June 1998. He had been assaulted five days earlier and attended medical review on the day of death, but presented as being in good s…
19y · Male·heroin toxicity
Marshall Carter, 19, died in custody from heroin toxicity at Yatala Labour Prison. He had a long history of drug abuse starting from age 14 and was an intravenous heroin user. Critical failures included: inadequate trans…
23y · Male·Incineration from motor vehicle accident (collision with tree)
A 23-year-old man who had experienced multiple suicide attempts and depression deliberately drove his stolen vehicle into a tree after police attempted to intercept him. He died from incineration. The coroner concluded t…
37y · Male·Traumatic intracranial haemorrhages/brain damage and fractured skull
A 37-year-old male died from traumatic intracranial haemorrhage and skull fracture after being punched and falling onto concrete. The critical clinical lesson is that head injuries may be completely undetectable on exter…
54y · Male·respiratory failure and acute renal failure due to rhabdomyolysis following trau…
A 54-year-old man with chronic schizophrenia and intellectual disability died from respiratory failure and acute renal failure secondary to rhabdomyolysis following a crush injury to his left thigh sustained while attemp…
29y · Male·left cerebrovascular accident (stroke) due to thromboembolism in the middle cere…
A 29-year-old male bodybuilder died from left cerebrovascular accident (stroke) caused by thromboembolism. He had a history of anabolic steroid use and presented after a minor motor vehicle accident on 6 April 1999. Imag…
24y · Female·Immersion (drowning due to hypoxic brain injury)
Syoko Tsubaki, a 24-year-old Japanese tourist and inexperienced recreational diver, died from drowning on 31 December 1998 after a scuba diving incident at Rottnest Island on 27 December. During an afternoon dive, the di…
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