53y · Male·decompensated alcoholic liver disease in the setting of gastro-intestinal haemor…
…vanced alcoholic liver disease (Child-Pugh C) died of decompensated liver disease with gastrointestinal haemorrhage. He was arrested for drunk in public place, lodged in police cells, and released in a deteriorated, soi…
4y · Female·Haemorrhage due to aorto-oesophageal fistula caused by ingestion of a button bat…
A 4-year-old girl died from aorto-oesophageal fistula and haemorrhage caused by a lithium button battery lodged in her oesophagus for at least 3 days. Critical diagnostic fa…
3y · Female·peritonitis caused by small bowel perforation due to blunt force trauma
A 3-year-old girl died from peritonitis caused by small bowel perforation. Expert evidence established the perforation resulted from blunt force trauma, not natural disease or accidental mechanisms. The manner of injury …
0y · Male·Complications following forceps delivery
A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) comple…
50y · Male·gastrointestinal haemorrhage; haemorrhage from cystic artery post laparoscopic c…
A 50-year-old man died from gastrointestinal haemorrhage involving both a cystic artery and duodenal defect following laparoscopic cholecystectomy. Over five da…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respira…
71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…
Sandra Cree, a 71-year-old woman, died from a ruptured abdominal aortic aneurysm (AAA) after undergoing an elective endovascular repair procedure in Brisbane. She presen…
41y · Female·Multiple injuries from assault
A 41-year-old woman with physical disability and stable mental health was killed by her adult son through severe blunt force trauma including extensive rib fractures causing flail chest, pneumohaemothorax, liver lacerati…
67y · Female·perforated gastric ulcer; morphine toxicity also made a significant contribution
Mrs Lillian Shaw, a 67-year-old obese woman with a history of NSAID use, presented with vomiting and abdominal pain over 36 hours. A GP visited three times without performing adequate physical examination, failed to…
0y · Male·severe hypoxic ischaemic encephalopathy secondary to uterine rupture
… Busselton Hospital occurred; emergency caesarean section revealed complete uterine rupture with baby in abdominal cavity. Baby AM was severely hypoxic at birth and died 3 days later. Key issues: Ms M had risk factors i…
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treatin…
1y · Male·Parainfluenza, pneumonitis and asthma; haemorrhagic mucositis of the bowel and g…
Tyler Di Blasi, aged 14 months, died from complications of acute lymphoblastic leukaemia (ALL) treatment. He developed parainfluenza pneumonitis, severe asthma, chemotherapy-induced neutropenia, thrombocytopenia, and gas…
Multiple traumatic injuries due to motor vehicle collision
This inquest examined the deaths of four young people in a motor vehicle collision on the Cunningham Highway near Warwick on 5 January 2008. The primary investigative issue was determining who was driving the Honda Civic…
75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…
A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…
27y · Female·Intracranial haemorrhage with associated blunt head, chest and abdominal trauma
A 27-year-old Aboriginal woman was killed by her violent partner while he was on parole with conditions explicitly prohibiting contact with her. Despite documented escalating domestic violence over 12 years (including bo…
Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…
This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…
Blunt force trauma sustained in level crossing collisions between heavy vehicles…
Coronial investigation into 26 deaths at 12 level crossing incidents in Victoria between 2002-2009, with focus on the Kerang incident (5 June 2007) where 11 train passengers died after a semi-trailer collided with a pass…
1y · Male·Complication of burns and trauma to the mesenteric artery
A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unk…
62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…
A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy fo…
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