391 results
75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…
Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the plann…
56y · Male·acute exacerbation of chronic obstructive pulmonary disease (bronchial asthma) i…
Ashley Adrian Lane, a 56-year-old Aboriginal man from the Ngaanyatjarra Lands, died in custody at Kalgoorlie Regional Hospital from acute exacerbation of chronic obstructive pulmonary disease (asthma). He was a remand pr…
heat stroke (environmental exposure) / hyperthermia; Mr Buske: atherosclerotic h…
Four deaths occurred on Mount Augustus summit trail in 2019-2020 during hot weather conditions. All deceased experienced heat stroke with dehydration as the primary mechanism of death. The coroner identified inadequate p…
33y · Male·Gunshot injury to the anterior trunk (chest and upper abdomen)
Desmond Jack, a 33-year-old with longstanding bipolar affective disorder and psychotic symptoms, died from a single gunshot wound to the anterior trunk after being shot by police officer Senior Constable Harrison on 28 M…
68y · Male·Complications following myocardial infarction and its treatment in a man with mu…
Salvatore Otranto, a 68-year-old prisoner with multiple severe comorbidities including ischaemic heart disease, diabetes, COPD, and chronic kidney disease, died from complications of myocardial infarction and its treatme…
58y · Male·Hypertensive and valvular heart disease
Kevin McCracken, 58, died of hypertensive and valvular heart disease following sudden cardiac collapse in a prison pre-release unit. He had complex pre-existing cardiac disease including previous valve replacement and ao…
45y · Male·bronchopneumonia and combined drug toxicity
Boris Drleski, a 45-year-old with treatment-resistant chronic paranoid schizophrenia, antisocial personality disorder, and polysubstance use disorder, died from bronchopneumonia and combined drug toxicity. He was managed…
26y · Female·hypoxic ischaemic encephalopathy and bronchopneumonia in a woman with methylamph…
Ms Cherdeena Wynne, a 26-year-old Noongar Yamatji woman, died from hypoxic ischaemic encephalopathy and bronchopneumonia following cardiac arrest during police restraint on Albany Highway. She was intoxicated with methyl…
31y · Male·Complications in association with intestinal volvulus
31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…
59y · Male·metastatic lung cancer, with palliation
Van Tho Nguyen, a 59-year-old remand prisoner with metastatic lung cancer, died of natural causes in a private hospital palliative care setting. He had been a lifelong smoker who developed advanced adenocarcinoma with bo…
20y · Male·head and neck injuries sustained when struck by train
Jordan James Williams, 20, died after being struck by a train following two absconsions from Kalgoorlie Health Campus mental health unit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Crit…
52y · Male·complications in association with advanced malignancy (hepatocellular carcinoma)…
Jeffrey Lee Strettles, a 52-year-old prisoner, died from complications of advanced hepatocellular carcinoma, end-stage cirrhosis, and generalised sepsis. He had contracted Hepatitis C in the late 1980s and was diagnosed …
55y · Male·Subdural haematoma in a man with diabetes mellitus and chronic kidney disease (r…
A 55-year-old Aboriginal man with end-stage renal disease, diabetes, ischaemic heart disease and COPD died from a spontaneous subdural haematoma while undergoing haemodialysis in prison custody. He presented with headach…
61y · Male·metastatic oesophageal neuroendocrine carcinoma
Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attribut…
29y · Male·ligature compression of the neck (hanging)
Brett Ashley Duturbure, aged 29, died by suicide via hanging at Wyndham Work Camp on 14 November 2019. The coroner identified critical systemic failures in the Department of Justice's management of his care. The Departme…
38y · Male·cardiac arrhythmia with acute circulatory failure in a man with acute drug effec…
Ohm Sathitpittayayudh, aged 38, died in custody at Karnet Prison Farm from cardiac arrhythmia with acute circulatory failure after ingesting 5F-ADB (Kronic), a synthetic cannabinoid. He had exemplary prison behaviour, go…
29y · Male·acquired methaemoglobinaemia in association with sodium nitrite toxicity
Elia Wani, a 29-year-old man with bipolar affective disorder managed on a community treatment order, died from methaemoglobinaemia following sodium nitrite ingestion. He purchased 50g of sodium nitrite powder online on 1…
16y · Female·acute abdominal obstruction secondary to adhesions associated with severe pelvic…
A 16-year-old Aboriginal girl died on Christmas Day 2016 from acute abdominal obstruction secondary to severe pelvic inflammatory disease caused by untreated gonorrhoea. Miss T presented to the ED twice with abdominal pa…
50y · Male·subarachnoid and intracerebral haemorrhage in association with a ruptured berry …
Joseph Thomas Roe, age 50, died from a ruptured berry aneurysm causing subarachnoid and intracerebral haemorrhage. He was a prisoner at Casuarina Prison when he called for medical assistance on the night of 17-18 Septemb…
38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…
Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute car…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.