1,232 results
26y · Male·self-inflicted gunshot wound to the head while suffering severe depression
Morgan Hill, a 26-year-old NSW police officer, died by self-inflicted gunshot wound in March 2009 while severely depressed. Over 20 months prior to death, he experienced escalating mental health difficulties with work ab…
29y · Male·acute bronchopneumonia complicated by multi-drug toxicity
Nicholas Ang, aged 29, with schizoaffective disorder, died from acute bronchopneumonia complicated by multi-drug toxicity while in a psychiatric unit. Admitted 12 August 2005, he was on clozapine, valproic acid, and clon…
91y · Female·asphyxiation due to neck entrapment on KA524 bedpole following fall from bed
Martha McKee, 91, died from asphyxiation when her neck became entrapped on a KA524 bedpole after falling from bed at Mid Richmond Aged Care on 28 July 2010. Multiple systemic failures contributed: one night carer was res…
Male
Christopher Michael Howse disappeared in May 1983. On balance of probabilities, the coroner found he died during or shortly after his disappearance, but the available evidence does not permit determination of the cause o…
3y · Female·Drowning
Three-year-old Meika Hawes drowned in her family's backyard swimming pool in Broken Hill on 30 November 2009. The coroner found the death resulted from two critical failures: inadequate supervision of the young child and…
21y · Male·Suicide by hanging
A 21-year-old Aboriginal man with schizophrenia and depression died by suicide in prison custody. Key clinical failures included: (1) inadequate mental health assessment by Dr S.—45-minute screening reviewing only one of…
1y · Female·Drowning
Isabela Fresco, a 1-year-old girl, drowned in her backyard swimming pool on 10 January 2010 after gaining access through an unsecured gate with a broken, non-self-locking mechanism. The coroner found that while inadequat…
8y · Male·Septic shock consequent on burst appendix with peritonitis
Jacob Belim, aged 8, presented to a GP with appendicitis on 24 March 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Li…
Unknown·Lignocaine toxicity following dental surgery with atherosclerotic and valvular h…
George Godden died at Prince of Wales Hospital on 22 February 2007 from lignocaine toxicity following dental surgery. His post-extraction gingival bleeding was treated with gauze soaked in co-phenylcaine spray, a medicat…
Drowning while rock fishing; swept from rock platforms by large waves or fell fr…
This inquest examined 12 deaths from rock fishing in NSW across 2009-2010, all caused by drowning after victims were swept from rock platforms by large waves. Deaths occurred at multiple dangerous coastal locations inclu…
47y · Unknown·Multiple gunshot wounds inflicted by person(s) unknown with intention to cause d…
On 26 January 2003, Milivoje Matovic, aged 47, was found dead at his residence in Elizabeth Bay, NSW, following multiple gunshot wounds. Investigation established that the injuries were inflicted intentionally by an unkn…
29y · Male·carbon monoxide poisoning
Janesh Dani, a 29-year-old security guard, died of carbon monoxide poisoning on 27 June 2002 in the gymnasium of a Pyrmont apartment complex where he worked. The coroner determined CO from an external pool heater accumul…
Unknown·Gunshot wound to the head
Ramon Khananyah was fatally shot in the head in Fairfield, NSW on 31 October 2005. A coroner's inquest held in July 2011 found that he died from a gunshot wound inflicted by one or more persons unknown acting in concert.…
15y · Male·multiple blunt force injuries as a result of being hit by a train
AB, a 15-year-old boy with depression and suicidal ideation, was prescribed Lexapro (escitalopram) by his GP despite it not being registered for use in adolescents. The coroner identified significant failures in clinical…
Male·Faecal peritonitis due to perforated diverticulum
Michael Sutherland presented to Bega Hospital Emergency Department on 2 March 2006 with severe abdominal pain from diverticulitis with bowel perforation. Dr B., the attending Career Medical Officer, formed an unfounded b…
Male·Blast injuries and multiple injuries from explosion caused by ethanol vapours ig…
Trevor Drayton (52, winemaker) and Edgar Orgo, an experienced welder, died on 17 January 2008 in an explosion at Draytons Winery, Pokolbin NSW. The explosion originated in Tank 104 containing 9000 litres of SVR (spiritus…
MDMA toxicity as a result of voluntarily ingesting that drug
Francesco Froio died at Liverpool Hospital on 16 February 2008 from MDMA toxicity following voluntary ingestion of the drug. The inquest (heard 7–9 March 2011) did not identify clinical failures but made administrative r…
42y · Male·Hanging (self-inflicted) while suffering from serious mental illness
Brian Dunningham, aged 42, died by hanging at Bathurst Correctional Complex (9–10 September 2009) while in custody. He had serious mental illness (psychosis, depression) requiring antipsychotic and antidepressant medicat…
40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…
Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…
11y · Male·Comminuted fractured skull with cerebral oedema from being run over by the rear …
Paul Carpenter, 11, died from blunt force trauma after falling under a school bus while "bus surfing" (hanging onto the emergency footrest) at a bus stop in Junee, NSW. The coroner found this dangerous behavior occurred …
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