139 results
22y · Male·multiple injuries due to motor vehicle accident
A 22-year-old provisional motorcycle licence holder died from multiple injuries sustained in a motor vehicle collision on 20 February 2017. He was riding a borrowed Harley Davidson motorcycle (1690 cc engine) and attempt…
55y · Male·Septicaemia due to hydronephrosis and infection
A 55-year-old man with complex medical and social problems died of septicaemia from renal infection. He had a history of cardiac disease requiring anticoagulation, alcohol dependence, depression, and chronic hoarding beh…
82y · Female·Acute bronchopneumonia
Gwenda Margaret Membery, an 82-year-old resident of aged care with dementia, COPD, and diabetes, died from acute bronchopneumonia. She presented with fever and cough on 3 July 2014, was diagnosed with respiratory tract i…
21y · Male·combined effect of a cocktail of drugs causing central nervous system depression…
Paul Fennessy, a 21-year-old with polysubstance addiction and mental health issues, died from positional asphyxia following a drug overdose on 6 January 2010. He presented to the Emergency Department that afternoon after…
21y · Male·combined effect of a cocktail of drugs taken by him, which caused central nervou…
Paul Fennessy, 21 years old, died from a cocktail of drugs causing central nervous system and respiratory depression with positional asphyxia on 6 January 2010. He had a decade-long history of polysubstance abuse, doctor…
1y · Male·Drowning in an unfenced in-ground home swimming pool
A 21-month-old boy drowned in an unfenced in-ground home swimming pool after leaving supervised care for approximately 30 minutes. The coroner identified two key clinical lessons: (1) the critical importance of active, c…
52y · Male·hypoxic-ischaemic encephalopathy due to or as a consequence of head, facial and …
A 52-year-old man died from hypoxic-ischaemic encephalopathy following traumatic head injuries sustained when the front fork of his Trek 2000 racing bicycle catastrophically failed during normal riding. Expert evidence e…
94y · Male·blunt head and neck trauma with associated haemorrhage; neck trauma included fra…
Charles Rowan McCulloch, aged 94, died from blunt head and neck trauma sustained in an assault by another dementia resident in Jindalee Aged Care Residence, ACT. He was admitted on 20 January 2012 and found deceased on 2…
32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin
A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…
37y · Male·Hanging, self-inflicted with intention of taking own life
A 37-year-old man with schizophrenia and a history of medication non-compliance died by suicide while subject to a Psychiatric Treatment Order. He was last seen alive on 14 February 2010 and found hanging on City Hill on…
46y · Male·asphyxia by hanging
Peter Zovak, a 46-year-old with substance use history, presented to mental health services in November 2013 with first-episode psychosis. After initial hospital assessment and two CAT Team visits, his case was closed on …
69y · Male·asphyxia by hanging
A 69-year-old man with depression, prostate cancer, and recent suicide attempt was admitted to MAPU (general medical ward) after intensive care treatment. He was deemed low suicide risk and the one-on-one attendant was d…
56y · Female·hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and f…
Sukanya Thurairajah, 55-year-old with multiple comorbidities including obesity, diabetes, coronary disease, and metastatic breast cancer, underwent haemodialysis at Canberra Hospital on 29 July 2011. She had an adverse r…
0y · Male·Motor vehicle collision injuries
On 20 March 2010, a motor vehicle collision on Canberra Avenue, Narrabundah, ACT, killed four people: an infant (Brody Lee Oppelaar, 3 months), his father (Scott Raymond Oppelaar, 33), his mother (Samantha Leanne Ford, 2…
21y · Male·cardiac arrest caused by acute bilateral pneumonia
Stephen Moon, a 21-year-old with autism and intellectual disability, died following wisdom tooth extraction complicated by ventilator-acquired pneumonia. Although discharged early from ICU after 3 days, he developed bila…
27y · Male·Gunshot wound to the chest fired by Sergeant Matthew Gale of the Australian Fede…
Nathan Doherty, aged 27, died from a gunshot wound inflicted by AFP Sergeant Matthew Gale during a mental health crisis. Nathan had a long history of depression, anxiety, and alcohol abuse, with two prior suicide attempt…
2y · Male·Cardiac and respiratory arrest consequent upon accidental immersion and drowning…
Daniel Weissegger, aged 2.5 years, drowned in a backyard swimming pool on 25 December 2004 after accessing the pool through sliding doors from a playroom that did not comply with Australian Standard 1926.1-1993. The door…
18y · Female·unknown - suspected homicide
Megan Louise Mulquiney, aged 18, disappeared on 28 July 1984 from the Woden Plaza in Canberra while working a part-time security job. Despite extensive police investigations and this inquest, her remains have never been …
33y · Female·heroin toxicity
Yvette Havet, a 33-year-old woman recovering from alcohol and drug addiction, died of heroin toxicity in May 2007. The coroner found that her fiancé administered the lethal injection, though she had also consumed substan…
Female·retroperitoneal blood loss in a setting of anticoagulation therapy following hip…
Valerie Kolts died from retroperitoneal blood loss following hip replacement surgery while on anticoagulation therapy. The coroner found no lack of care contributed to her death. Although some clinical signs were retrosp…
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