3,734 results
37y · Male·Neck compression in the setting of prone restraint in a man using methylamphetam…
Ahmet Gezer, a 37-year-old man under the influence of methylamphetamine, died from neck compression following a prone restraint during a physical altercation with Kristen Gascoyne. After an initial confrontation involvin…
58y · Male·Aspiration pneumonia in a man with Down's syndrome and dementia
John Sloots, a 58-year-old man with Down's syndrome and dementia, died from aspiration pneumonia. He had a documented longstanding swallowing impairment that had been deteriorating, and was identified as high-risk for as…
48y · Male·Fatal cardiac arrhythmia which was the result of obstructive sleep apnoea
Jason Radford, a 48-year-old First Nations man, died of fatal cardiac arrhythmia secondary to obstructive sleep apnoea while in custody at Junee Correctional Centre. He had multiple comorbidities including obesity, type …
41y · Female·Multiple injuries
Alicia Maree Little, aged 41, was struck and killed by a motor vehicle driven by her former intimate partner while she was leaving the relationship. The case highlights significant systemic failures in family violence re…
27y · Male·Multiple injuries sustained in a fall from height
Reece Pullen, 27, died from multiple injuries sustained in a fall from a seventh-floor balcony on 27 October 2021. He had a history of drug-induced psychosis following methamphetamine use, treated at Orygen Youth Health …
30y · Male·Gunshot wounds to the chest
Gabriel Messo, a 30-year-old man with bipolar affective disorder, died from gunshot wounds inflicted by Victoria Police on 16 July 2020 after violently assaulting his mother at John Coutts Reserve. Clinical lessons inclu…
83y · Male·aspiration pneumonia
Ellis Newton Hughes, 83-year-old retired mining engineer with metastatic prostate cancer, sustained a femoral fracture in a fall on 5 February 2020. He underwent open reduction and internal fixation on 10 February 2020 a…
55y · Female·exsanguination due to a gunshot wound to the upper left chest
A 55-year-old woman with a 20-year history of depression died from a self-inflicted gunshot wound. She had attempted suicide twice in 2019 (July and December) and was managed by her general practitioner and Tasmania Heal…
74y · Male·Pericarditis post aortic valve surgery with large pericardial effusion leading t…
Ian Dunlop, a 74-year-old man, died from pericarditis with large pericardial effusion and tamponade four days after aortic valve replacement surgery. Post-operative imaging showed a small pericardial effusion, considered…
61y · Male·hanging
Andrew Robert Young, a 61-year-old man with lifelong depression and social phobia, died by hanging on 13-14 January 2020. He had received consistent psychiatric care from an experienced psychiatrist for 16 years using su…
58y · Male·complications of large bowel pseudo-obstruction
Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal…
Male·mixed prescription drug toxicity (tramadol and diazepam)
Daniel Wayne Dare died from mixed prescription drug toxicity involving tramadol and diazepam. He had a history of chronic lower back pain and depression managed with these medications prescribed by his GP over several ye…
41y · Male·Gunshot wounds to the head and torso
Duy Linh Ho, a 41-year-old man with long-standing substance use disorder and untreated mental health issues, died from gunshot wounds after a police response to his self-harm and suicidal crisis. He had used methamphetam…
59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma
Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite M…
23y · Male·Undetermined
A 23-year-old male died from an undetermined cause following a night of cocaine and nitrous oxide use. He experienced paranoid and delusional thoughts, hallucinations about demonic possession, and reported chest pain and…
90y · Female·Multiple rib and pelvic fractures due to a fall from a wheelchair on sloping lan…
Cynthia Stevens, aged 90, died from multiple fractures sustained when her wheelchair rolled uncontrolled down a steep slope in a medical car park. The primary clinical lessons include: (1) inadequate application of wheel…
44y · Male·gunshot wound to the abdomen
Vlado Micetic, 44, was fatally shot by Leading Senior Constable Timothy Baker during a traffic interception for stolen number plates in Windsor, Victoria, on 25 August 2013. Baker claimed Micetic produced a knife during …
25y · Male·Ruptured berry aneurysm and sequelae resulting in catastrophic subarachnoid and …
A 25-year-old Aboriginal man on remand in custody collapsed during a shower and was found to have suffered a catastrophic ruptured berry aneurysm causing massive subarachnoid and intracerebral haemorrhage with brain deat…
65y · Female·Pneumonia and right hip haematoma following a fall in a woman with multiple medi…
Glenda Shapcott, a 65-year-old woman with intellectual disability and multiple comorbidities, died from pneumonia and hip haematoma following a fall. She lived in supported disability accommodation and was under a pallia…
57y · Female·Positional asphyxia
AA, aged 57, died from positional asphyxia following a fatal assault by her brother BB during a family dispute about money and aged care responsibilities. BB was caring for their elderly father GG, who had recently been …
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