84y · Male·severe head injuries (fracture of skull on right side, subarachnoid haemorrhage,…
An 84-year-old man with severe respiratory disease, cardiac failure, poor vision and confusion fell from a first-floor hospital window, sustaining fatal head injuries. The coroner found the death was not deliberately sel…
4y · Female·Immersion (drowning)
Kaitlin Alyce Gubanyi, a healthy 4-year-old girl who could swim, drowned in a backyard swimming pool on 30 March 1999. While being supervised by a neighbour, Mrs Vicki Parr, the child was discovered face down in the pool…
20y · Male·ruptured heart and aorta due to fall from a height
A 20-year-old male with newly diagnosed disorganised schizophrenia died by suicide from a fall from the 5th floor of a hospital maternity building while detained under the Mental Health Act. He had been admitted to the C…
53y · Male·asphyxia due to upper airway occlusion by a foreign body (blanket)
A 53-year-old man with complex psychiatric disorder (schizophrenia, depression, intellectual disability) died by asphyxiation after stuffing a blanket into his mouth while in a High Dependency Unit of a psychiatric hospi…
22y · Male·Ligature Compression of the Neck (Hanging)
Dean Kieran Lauder, aged 22, died on 31 May 1998 at Canning Vale Prison by ligature strangulation (hanging) while in a punishment cell. He was serving a 7-day sentence for cannabis possession offences. He had a history o…
34y · Female·hypoxic brain damage complicating fresh water drowning
Alice Louise McTye, a 34-year-old woman with severe intellectual disability and epilepsy, died from hypoxic brain damage following fresh water drowning in a bath at a disability services residence. The coroner found she …
60y · Male·undetermined; presumed suicide by motor vehicle driving over cliff
Robert Hutchinson, aged 60, disappeared on 18 April 1999 after receiving a phone call from his nephew regarding historical sexual abuse allegations. He made explicit statements to his partner about intending to die, wrot…
16y · Male·Internal haemorrhage due to closed chest and abdominal injuries sustained in mot…
Todd Best, aged 16, died from internal haemorrhage following blunt chest and abdominal trauma sustained when struck by a police vehicle while evading custody. He had been arrested for property damage, placed in the front…
80y · Male·bronchopneumonia complicated by morphine toxicity
An 80-year-old man with terminal liver disease died from bronchopneumonia complicated by morphine toxicity following a medication administration error. A Graseby infusion pump was incorrectly set at 99mm/hour instead of …
0y · Female·premature delivery; extreme prematurity
A 19-week pregnant woman was admitted for pregnancy termination due to maternal psychological concerns. Labour was induced with misoprostol, expecting foetal death in utero or delivery of non-viable remains. Instead, a l…
47y · Male·Ligature compression of the neck (hanging)
Kenneth John Groth, aged 47, died by hanging in Casuarina Prison on 9 April 1998. He was a sentenced prisoner convicted of sexual offences, serving a 10-year sentence. His appeal was adjourned and legal aid was refused, …
42y · Female·salt water drowning
Sandra Sanders, aged 42, a detaineε psychiatric patient, died by saltwater drowning after absconding from Woodleigh House psychiatric unit on 3 September 1997. She had presented with major depression with psychotic featu…
73y · Male·dehydration and hyperthermia
A 73-year-old man with mild dementia resident in aged care wandered from the facility on a hot day (31°C+) while taking three medications with anticholinergic properties: pericyazine, haloperidol, and oxybutynin. These d…
78y · Male·suppurative bronchitis complicating chronic obstructive airways disease (emphyse…
A 78-year-old man died of suppurative bronchitis complicating end-stage emphysema at a supported residential facility. Key clinical concerns include: (1) the general practitioner's reliance on unvetted aged care staff to…
70y · Male·spontaneous left frontal intracerebral haemorrhage
A 70-year-old man incarcerated at Yatala Labour Prison died from spontaneous left frontal intracerebral haemorrhage at Modbury Hospital. He had pre-existing chronic obstructive pulmonary disease, severe interstitial lung…
27y · Female·Ligature compression of neck (hanging)
Lorna Silvester, a 27-year-old woman with depression and suicidal ideation, died by hanging on 18 January 1999 while on approved leave from Graylands Hospital. She had been admitted involuntarily on 13 January after pres…
34y · Male·aspiration pneumonia following seizure with concomitant global severe anoxic enc…
Kenneth Strangways, a 34-year-old Aboriginal man with post-traumatic epilepsy, organic brain damage from head injuries, alcoholism and psychiatric illness, died from aspiration pneumonia following a seizure. The death wa…
30y · Male·acute combined heroin and alcohol toxicity; ingestion of alcohol and heroin
Michael James Dwyer, a 30-year-old man, died on 17 June 1999 at Royal Perth Hospital from acute combined heroin and alcohol toxicity. On 11 June, after returning from Melbourne, he consumed approximately one litre of gin…
3y · Male·smothering
A 3-year-old boy died from smothering by his mother, who was suffering from severe bipolar affective disorder with psychotic features and severe depression. The coroner examined whether psychiatric care was inadequate. T…
Male·Head Injuries sustained from motor vehicle collision
Neil Kingsley Rushton died on 27 November 1997 after being struck by a motor vehicle whilst lying on Lyon Road, Wandi, Western Australia. He sustained fatal head injuries from the collision. The circumstances of how he c…
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