918 results
83y · Male·General inanition and aspiration pneumonia on a background of end-stage Alzheime…
An 83-year-old man with end-stage Alzheimer's dementia died from general inanition and aspiration pneumonia while subject to a Mental Health Act order in hospital. He had experienced two episodes of aspiration pneumonia …
87y · Male·infective exacerbation of chronic obstructive lung disease
An 87-year-old man with a long smoking history and no prior diagnosis of lung disease suffered a hip fracture requiring surgery. Postoperatively, he developed delirium and hypoxia. Two Inpatient Treatment Orders were app…
57y · Male·brainstem and cerebellar infarction due to vertebrobasilar artery thrombosis
A 57-year-old man with multiple cardiovascular risk factors presented to an ED with vertigo, blurred vision, and 'not feeling right' caused by an evolving posterior circulation stroke. A junior doctor discharged him afte…
53y · Male·lung abscess with empyema
A 53-year-old man with schizophrenia died from lung abscess with empyema while an involuntary inpatient at a mental health facility. He had been readmitted with a respiratory infection and was treated with intravenous an…
42y · Female·hanging
Holly Thredgold, aged 42, died by hanging on 28 August 2016, less than 40 hours after inappropriate discharge from Royal Adelaide Hospital ED. She presented on 26 August 2016 severely intoxicated with suicidal ideation a…
42y · Female·multiorgan failure complicating hyperthermia and metabolic acidosis following su…
A 42-year-old woman with long-standing depression, substance use issues, and multiple mental health presentations died from multi-organ failure following ingestion of caustic soda. She was found unresponsive at home on 1…
95y · Female·acute left subdural haematoma complicating anticoagulant therapy for deep vein t…
A 95-year-old woman with multiple comorbidities including congestive heart failure was admitted with suspected pneumonia and cellulitis. She developed deep vein thrombosis and was started on enoxaparin anticoagulation. S…
35y · Male·plastic bag asphyxia
Travis Glen Perrin, aged 35, died by plastic bag asphyxia while on home detention bail with electronic monitoring following arrest for a child sex offence. He had been residing with his father in Loxton for approximately…
34y · Male·hanging
Daniel Sergio Petruzzella, a 34-year-old man on home detention bail with electronic monitoring following family violence allegations, died by hanging on 31 October 2019. He had been arrested 9 August 2019 and released to…
8y · Female·Multiple injuries sustained when ejected from amusement ride
Adelene Leong, age 8, was ejected from the Airmaxx 3601 amusement ride at the Royal Adelaide Show on 12 September 2014 and died from multiple injuries. The coroner found her death was preventable. Critical failures inclu…
80y · Male·Dehydration and the effects of heat with contributing Alzheimer's dementia
An 80-year-old man with advanced Alzheimer's dementia disappeared from a respite care facility on a day of extreme heat (39°C) and died from dehydration and heat exposure. Key failures included: (1) relocation of the day…
Unknown·Amber Rose Rigney: external airway occlusion with compression of the neck; Korey…
Two children, Amber Rose Rigney (6) and Korey Lee Mitchell (5), were murdered on 30 May 2016 by their mother's partner Steven Graham Peet. The Coroner found their deaths were preventable. The children's mother had been u…
Unknown·exposure to the sea
Three family members died at sea on 12 December 2016 after their boat disappeared from Cape Jaffa marina, South Australia. The 7-metre aluminium-hulled boat was launched at 10:33am with Lennel (56), Annette (56), and Dou…
76y · Male·combined effects of acute myocardial infarction and urosepsis
Pasquale Esposito, age 76, died in custody at Lyell McEwin Hospital from combined acute myocardial infarction and urosepsis. He had extensive cardiac history including prior MI, CABG, COPD, and recent stent placement. On…
80y · Male·general inanition and pneumonia on a background of advanced vascular dementia, c…
Ian Ross Lauder, aged 80, died at an aged care facility from pneumonia and general inanition on a background of advanced vascular dementia, cerebrovascular disease, and a recently operated right hip fracture. He had suff…
97y · Male·respiratory failure attributed to aspiration pneumonia on a background of advanc…
Richard Underwood, aged 97, died from respiratory failure due to aspiration pneumonia on a background of advanced dementia, a surgically repaired neck of femur fracture, and gastrointestinal haemorrhage. He was admitted …
20y · Female·multi-organ failure due to polypharmacy overdose
A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where i…
70y · Male·advanced left frontal glioblastoma (operated)
A 70-year-old male prisoner died from advanced left frontal glioblastoma. The tumour was identified when he presented with acute stroke-like symptoms (facial droop, weakness, confusion) in July 2018 while imprisoned. He …
56y · Female·sepsis secondary to disseminated pancreatic adenocarcinoma
Julie Michele Dunn, a 56-year-old female prisoner, died of sepsis secondary to disseminated pancreatic adenocarcinoma. She had presented months earlier with gastrointestinal symptoms (weight loss, nausea, vomiting, epiga…
68y · Male·decompensated heart failure with pulmonary hypertensive crisis complicated by pn…
Peter Hohol, a 68-year-old prisoner with significant cardiac comorbidities including ischaemic and dilated cardiomyopathy, died from decompensated heart failure with pulmonary hypertensive crisis complicated by pneumonia…
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