1,232 results
3y · Male·unascertained
KP was a 3-month-old with intrauterine growth restriction born to a mother with documented mental health issues and cannabis use. Despite referral to SAFE START and child protection involvement, care coordination and fol…
71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…
56y · Male·Multiple injuries sustained in a motor vehicle collision
Harri Jokinen, aged 56, died following a head-on motor vehicle collision on the Monaro Highway when a stolen Commodore being pursued by NSW police crossed into his lane. Clinical lessons: This was a non-medical death but…
90y · Male·pneumonia complicating ischaemic heart disease
Francis William Athol Cable, aged 90, died in the Corrective Services NSW Secure Annex at Prince of Wales Hospital on 12 September 2022. He had complex medical comorbidities including ischaemic heart disease, chronic car…
43y · Male·undetermined - body not recovered
Ashley McKellar, a 43-year-old engineer, went missing on 14 June 2023 while operating his vessel near Swansea, NSW. His unmanned boat was found 30 nautical miles east of Swansea the following day. Despite extensive searc…
33y · Male·sharp force injuries of the neck
Malcolm Brown, a 33-year-old Aboriginal man with a history of methamphetamine use, mental health crisis, and self-harm threats, died from sharp force injuries to his neck on 29 June 2022 following a NSW Police operation.…
25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…
Emmett Brown, a 25-year-old First Nations man, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvida…
2y · Female·sequelae of blunt force head and spinal cord injuries
DB, aged 2 years 9 months, died from blunt force head and spinal cord injuries inflicted by her mother's boyfriend after DCJ closed its case in August 2015. The coroner found DCJ made multiple critical failures: acceptin…
40y · Male·septic complications from injuries received from multiple dog bites sustained on…
Colin Amatto, a 40-year-old Yuin man, died from septic complications following a devastating dog attack with over 80 bite wounds. Critical clinical lesson: the same dog (Boof, a Staffordshire Bull Terrier) had attacked a…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
27y · Male·acute myeloid leukaemia
Hayden Dawes, aged 27, died from acute myeloid leukaemia (AML) while in custody at Mannus Correctional Centre on 30 December 2018. He had previously been treated for Hodgkins Lymphoma with BEACOPP chemotherapy (2014-2016…
7y · Female·Group A Streptococcus (Streptococcus pyogenes) pneumonia with sepsis
A 7-year-old previously healthy girl died from Group A Streptococcus pneumonia with sepsis after paramedics failed to transport her to hospital despite recording a severely elevated heart rate (172 and 168 bpm) on 15 Sep…
41y · Male·Multiple traumatic injuries
This inquest examined the death of a 40-year-old man who died by suicide following a fall from a cliff. He had three involuntary admissions to mental health facilities in a fortnight before his death. Critical clinical l…
62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval
NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with …
84y · Male·haemoperitoneum due to ruptured abdominal aortic aneurysm
Bernard Greenwell, an 84-year-old male, died from rupture of an abdominal aortic aneurysm (AAA) while in custody at Cessnock Correctional Centre. He experienced sudden-onset severe left groin pain at 11:30am on 25 April …
64y · Female·Unascertained
A 64-year-old woman with chronic pain from multiple joint replacements, significant depression following her daughter's death in 2006, and long-standing suicidal ideation disappeared from a cruise ship in the Tasman Sea …
38y · Male·gunshot wounds to the chest
Warren Matthew Simon, a 38-year-old Awabakal man with a history of substance abuse, mental health issues, and extensive criminal convictions, died from gunshot wounds to the chest after police attended a break-in at 80 B…
41y · Male·multiple blunt force injuries from fall from fourth floor of apartment block
Brent Reginald Pottinger, 41, died from multiple blunt force injuries after falling from a fourth-floor apartment while attempting to access his partner's balcony in the early morning of 13 May 2023. He had been arrested…
59y · Female·multiple injuries from fall from height
Fiona Turnbull, a 59-year-old woman with chronic schizophrenia on clozapine, died from multiple injuries after falling from her third-floor balcony on 12 October 2017 during a psychotic relapse. The death occurred shortl…
29y · Male·hanging
Muhammad Hafizuddin Bin Zaini, a 29-year-old detainee in immigration detention at Villawood, died by hanging on 12 December 2020. He had a history of substance-induced psychotic disorder and was prescribed antipsychotic …
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