295 results
80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…
Aurelio Monterlegre Cruz, an 80-year-old man with complex medical conditions including chronic renal failure, ischaemic heart disease, diabetes, and COPD, died of bronchopneumonia complicating terminal palliative care wh…
56y · Male·disseminated malignancy – known non-small cell carcinoma of lung
Colin George Graham, a 56-year-old Aboriginal man with severe COPD and lung cancer, died of disseminated non-small cell carcinoma while in prison custody receiving palliative care. The coroner found his medical care was …
31y · Female·incised wounds to the neck and arms
A 31-year-old illustrator with a recent onset of acute depression and suicidal ideation attended Fremantle Hospital ED via ambulance after GP referral on 12 May 2014. She had made a suicide attempt at a beach two days ea…
Male·Multiple: ligature compression of neck (hanging) in four cases; incised injury t…
Five male prisoners died by suicide at Casuarina Prison, Western Australia between 2014-2015. All deaths were by hanging or self-inflicted laceration. The coroner identified multiple systemic failures including: inadequa…
64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…
A 64-year-old woman with bipolar disorder, severe obstructive sleep apnoea, obesity and diabetes presented with acute psychotic relapse following stress and sleep deprivation. Initially admitted to ED where she was sedat…
40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…
Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensat…
24y · Male·bronchopneumonia complicating oxycodone toxicity
Matthew Neil Hardy Tonkin was a 24-year-old Australian Army veteran with post-traumatic stress disorder and chronic pain who died from bronchopneumonia complicating oxycodone toxicity. He engaged in prescription shopping…
36y · Male·Ligature compression of the neck (suicide by hanging)
A 36-year-old Aboriginal man with cluster B personality disorder, substance abuse, and chronic self-harm risk died by ligature suicide in prison 2 hours after admission. He pleaded guilty to arson charges and was remande…
34y · Male·ligature compression of the neck
Fazel Chegeni Nejad, a 34-year-old Iranian asylum seeker, died from ligature compression of the neck in the jungle near Christmas Island immigration detention centre on 8 November 2015. He had spent 1,477 days in detenti…
68y · Male·Bronchopneumonia in a man with chronic obstructive pulmonary disease
Maris Kugis, a 68-year-old man with chronic schizophrenia, personality disorders, and multiple serious physical conditions including COPD, ankylosing spondylitis, and undiagnosed pancreatic adenocarcinoma, died from bron…
39y · Female·pulmonary thromboembolism due to deep vein thrombosis and sepsis due to pyelonep…
Lorna May Woods, 39, died from pulmonary thromboembolism due to deep vein thrombosis and sepsis secondary to pyelonephritis on a background of metastatic ovarian cancer. She presented to Joondalup Health Campus with uros…
30y · Male·methadone toxicity
A 30-year-old man with schizoaffective disorder, narcolepsy, and obesity died from methadone toxicity while an involuntary psychiatric patient. He was prescribed multiple sedating medications including methadone, benzodi…
Ligature compression of the neck (hanging) in 12 cases; one open finding
This complex coronial inquest examined 13 Aboriginal children and young persons who died by suicide in the Kimberley Region between 2012–2016. The coroner found 12 deaths were suicides and one open finding. Common contri…
37y · Male·Subarachnoid haemorrhage due to ruptured berry aneurysm of the right middle cere…
A 37-year-old male prisoner with Ehlers-Danlos Syndrome died from subarachnoid haemorrhage due to a ruptured berry aneurysm at Karnet Prison Farm. He collapsed suddenly while appearing well minutes earlier. The coroner f…
Male·thermal injuries (burns)
Ali Jaffari, an immigration detainee, died by suicide at Yongah Hill Immigration Detention Centre on 16 September 2015. He sustained fatal thermal injuries from a fire he deliberately started in his room. The deceased ha…
24y · Male·seizure (epileptic)
Mohammad Nasim Najafi, a 24-year-old Afghan detainee with well-controlled epilepsy, died from a seizure after missing multiple doses of carbamazepine in the days preceding his death. He was held in immigration detention …
27y · Male·combined drug toxicity (U-47700 and etizolam)
Mark Sach, aged 27, died from combined drug toxicity involving U-47700 (a synthetic opioid 7.5 times more potent than morphine) and etizolam (a benzodiazepine 10 times more potent than diazepam), obtained via internet pu…
70y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis
A 70-year-old sentenced prisoner with severe ischaemic heart disease and prior myocardial infarctions died from acute myocardial infarction with coronary artery atherosclerosis. He presented with severe chest pain on 5 O…
45y · Male·Gunshot injury to the chest (self-inflicted)
Scott Andrew Blanchard, a 45-year-old Detective Sergeant with the Western Australian Police Gang Crime Squad, died from a self-inflicted gunshot wound while on duty near Kalgoorlie. In June 2015, following a trip to Thai…
69y · Male·bronchopneumonia and hypoxic brain injury following aspiration of food (choking)
A 69-year-old male with bipolar affective disorder and suspected frontotemporal dementia, admitted involuntarily to a psychiatric hospital, choked on bread while eating breakfast unattended and suffered a cardiac arrest.…
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