918 results
89y · Female·head injury
Barbara Ann Haynes, aged 89, died from a head injury sustained in a fall at an aged care facility on 29 March 2020, with death occurring 13 days later on 11 April 2020. She had Alzheimer's dementia, osteoporosis, and a h…
0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia
Bodhi Leo Searle, aged 36 hours, died from hypoxic ischaemic encephalopathy due to intrapartum asphyxia. He was born to a woman in low-risk labour managed initially by independent midwife Stephanie Geyer. When labour did…
54y · Male·hanging
Shane Michael Doran, aged 54, died by hanging whilst on home detention bail on 1 September 2020. He had been arrested for alleged assault offences and initially held in police custody, then remand, before being granted h…
29y · Male·severe neonatal encephalopathy, post palliative care; possible underlying cause:…
A 29-day-old neonate died from severe neonatal encephalopathy following birth asphyxia. The infant was born after prolonged induction and protracted second-stage labour at Lyell McEwin Hospital, followed by instrumental …
41y · Male·undetermined
Vaughan Weston Williamson, 41, died at Glenside Hospital while subject to a Level 3 Inpatient Treatment Order for treatment-resistant schizophrenia. Despite post-mortem examination including specialist neuropathological …
5y · Male·acute upper airway obstruction from nectarine stone
Lucas Mazzei, aged 5 years, died on 27 March 2017 from acute upper airway obstruction caused by an uncut nectarine stone. While attending school, he was separated from his class during a science lesson and left watching …
29y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to out of hospital …
Wayne Fella Morrison, a 29-year-old Aboriginal man with undiagnosed coronary artery disease (70% stenosis of right coronary artery), died following cardiac arrest during his detention at Yatala Labour Prison. After attac…
72y · Male·cerebral malignancy (glioblastoma multiforme)
Geoffrey Adams, aged 72, died in custody from glioblastoma multiforme (cerebral malignancy). He presented with acute neurological symptoms (slurred speech, facial droop, weakness) on 13 November 2020 during a routine med…
78y · Male·multi-organ failure complicating neck of femur fracture (operated) on a backgrou…
A 78-year-old man with multiple comorbidities (heart failure, renal disease, COPD) suffered a neck of femur fracture from an unwitnessed fall at an aged care facility. Post-operatively he deteriorated with acute renal fa…
13y · Male·Hanging
Zhane Chilcott, age 13, died by suicide at a residential care facility after 12 years in state care with 18 placements. The coroner found multiple systemic failures: inadequate scrutiny of his first placement with LB des…
27y · Male·hanging
A 27-year-old man with deteriorating mental health and acute psychotic symptoms died by hanging from a bathroom door in an acute mental health unit. He had expressed suicidal ideation, told his parents he needed to die t…
Female·haemopericardium due to aortic dissection (all three cases)
Three elderly women died from acute aortic dissection at Queen Elizabeth Hospital, South Australia. Beverley Coats (73) presented three times in July 2016 with back pain, nausea and vomiting; her known aortic dilatation …
72y · Male·acute cerebral infarction complicating acute myocardial infarction
Ronald Bromage, aged 72, died from acute cerebral infarction complicating acute myocardial infarction. He presented with chest pain on 22 and 25 February 2016 to his GP, Dr P., who diagnosed costochondritis without perfo…
69y · Male·plastic bag asphyxia and mixed drug toxicity (oxycodone and pentobarbitone)
John Abbott, aged 69, died from plastic bag asphyxia and mixed drug toxicity (oxycodone and pentobarbitone) while under home detention bail with electronic monitoring. He had a complex medical history including chronic o…
66y · Male·inanition and probable respiratory tract infection complicating Alzheimer's deme…
Peter Joseph Hammond, aged 66, died from inanition and probable respiratory tract infection complicating advanced Alzheimer's dementia. He was admitted to the Acute Older Persons Mental Health Unit at Flinders Medical Ce…
55y · Male·right intracerebral haemorrhage and left middle cerebral artery cerebrovascular …
Wayne Shore, 55, died from right intracerebral haemorrhage and left middle cerebral artery stroke complicating infective endocarditis, end-stage renal failure, and multiple myeloma. He was subject to a Level 1 Inpatient …
50y · Male·ischaemic heart disease
Paul Reid, a 50-year-old Aboriginal man with severe ischaemic heart disease and poor medication compliance, died of a cardiac arrhythmia during his arrest by South Australian Police. He was highly intoxicated (BAC 0.25%)…
84y · Male·acute aspiration complicating periprosthetic fractured right femur (operated) on…
Bryan Roocroft, 84 years old with severe dementia, suffered a periprosthetic right femur fracture after two falls at aged care on 24 December 2020 while on oxazepam. He underwent surgical repair on 25 December and was pl…
79y · Male·Iatrogenic right ventricular injury complicating drainage of pericardial collect…
A 79-year-old man died from iatrogenic right ventricular injury sustained during attempted drainage of a post-operative pericardial effusion following coronary artery bypass grafting. During a minimally invasive sub-xiph…
64y · Male·sodium nitrite poisoning
A 64-year-old man on home detention bail died from intentional sodium nitrite poisoning. He had a documented history of depression, anxiety, and suicidal ideation. His GP noted he was 'pretty much suicidal' in February 2…
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