3,434 results
47y · Male·Hanging
A 47-year-old man with chronic schizophrenia and alcohol dependence died by hanging at a rooming house. He had been non-compliant with antipsychotic medications for months, experiencing severe auditory hallucinations tha…
28y · Female·Complications of a seizure in the setting of prescription drug abuse (pregabalin…
Samantha Leech, 28, died from complications of a seizure in the setting of prescription drug abuse, particularly pregabalin. She obtained approximately 4000 pregabalin tablets over three months by visiting multiple GPs, …
62y · Female·Unascertained
Marilyn, a 62-year-old woman with schizophrenia and intellectual disability, died at Caulfield Hospital on 27 October 2019 with an unascertained cause. She was admitted via the ED under mental health legislation with det…
35y · Male·unascertained - multifactorial: underlying ischaemic heart disease, drug intoxic…
David Perry, aged 35, died from unascertained causes during police arrest at Bellbrae on 11 January 2019. He presented to The Alfred with acute paranoia, hallucinations and agitation following synthetic cannabis use, and…
62y · Male·Diabetic ketoacidosis in a man with coronary atherosclerosis and cardiomegaly
Phillip Sealey, 62, presented to his local GP on 27 June 2019 with three weeks of thirst, urinary frequency, nocturia, blurred vision, dizziness and vomiting. The GP diagnosed hypertension and suspected diabetes mellitus…
54y · Male·Toxic leukoencephalopathy (of uncertain aetiology)
David Main, 54, died from toxic leukoencephalopathy of uncertain aetiology following a ketamine-assisted oxycodone detoxification at Beleura Private Hospital. He had chronic pain from multiple injuries and opioid depende…
39y · Male·Complications arising from widely disseminated primary pulmonary small cell carc…
A 39-year-old male inmate died from complications of widely disseminated small cell lung cancer with hepatitis C cirrhosis. He presented with acute psychosis and catatonia in December 2018, receiving appropriate psychiat…
86y · Female·Plastic bag asphyxia
An 86-year-old woman with delirium, depression, and multiple cardiac comorbidities died by asphyxiation with a plastic bag while in a transitional care facility. She had expressed wishes to die, references to suicide, an…
37y · Male·Acute external and internal blood loss from single stab wound to upper left ches…
MWJ, aged 37, was fatally stabbed by his intimate partner EW on 24 December 2016 during an escalating domestic argument. The coroner identified significant systemic failures in Community Corrections management of both of…
52y · Female·Presumed SUDEP (Sudden Unexplained Death in Epilepsy)
Mariza Beretta, a 52-year-old woman with Trisomy 21 and early-onset Alzheimer's disease, died from presumed SUDEP (Sudden Unexplained Death in Epilepsy) at Royal Melbourne Hospital. She was diagnosed with genetic general…
1y · Male·Global cerebral ischaemia in an infant with upper airway obstruction
NB, a 14-month-old with a tracheostomy requiring overnight nursing support in foster care, suffered a cardiac arrest on 17 December 2016 that resulted in severe hypoxic brain injury and death. The overnight nurse (Ms Jar…
75y · Female·Multiple injuries including stab wounds to the chest
A 75-year-old woman was fatally stabbed by her son during a family violence incident. Her son had a 20-year history of schizophrenia and schizoaffective disorder with poor medication compliance, documented aggression tow…
44y · Male·Strangulation
Ashley Phillips, aged 44, was strangled to death by Jason Considine during a consensual sexual encounter on 26 May 2017. This finding reveals systemic failures in community corrections case management. Considine was subj…
71y · Male·Mixed drug toxicity
A 71-year-old man with multiple chronic conditions including obesity, diabetes, heart failure, and chronic pain died from mixed drug toxicity involving oxycodone, codeine, diazepam, and alcohol. The coroner determined he…
72y · Male·Multiple injuries sustained in a fall from a height
Peter Starkie, aged 72, died from multiple injuries sustained in a fall from a roof while cleaning a skylight at his partner's property in Shepparton. He fell approximately three metres onto concrete, sustaining fatal he…
45y · Male·Hanging
A 45-year-old man with depression died by hanging after experiencing significant workplace stress. He had consulted his GP in October 2014 regarding grief over his mother's terminal illness and was prescribed sleeping ta…
37y · Male·Combined drug toxicity (methadone, fentanyl, diazepam and pregabalin)
Daniel Joseph Herbert, aged 37, died from combined drug toxicity involving methadone, fentanyl, diazepam and pregabalin. He had a 17-year history of opioid dependence stemming from prescription OxyContin for a work-relat…
52y · Male·Aspiration Pneumonia
Gregory Bennett, a 52-year-old man with congenital rubella syndrome causing profound disabilities including dysphagia, epilepsy, and spastic quadriparesis, died from aspiration pneumonia. He was living in DHHS-managed ac…
61y · Female·Pneumonia in a woman with multiple co-morbidities
A 61-year-old woman with significant comorbidities including congenital hydrocephalus, stroke, obstructive sleep apnoea, and previous pneumonia with respiratory arrest (2017) died of pneumonia in hospital. She lived in a…
32y · Male·Multiple injuries sustained in a fall from a height
Adam Laufer, a 32-year-old man with longstanding bipolar disorder, died by suicide on 24 November 2016 when he jumped from the LaTrobe Street overpass in Melbourne. In the early hours of 24 November, his father called tr…
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