3,729 results
95y · Female·Complications post scooter versus car incident
A 95-year-old woman died from complications of injuries sustained in a collision between her motorised mobility scooter and a car while crossing Raymond Street in Sale. She suffered flail chest, hemopneumothorax, and spi…
64y · Male·Complications of a cerebral tumour in the setting of multiple medical comorbidit…
Brian Troy, a 64-year-old man with profound intellectual and physical disabilities including autism, epilepsy, and cerebral palsy, died from complications of a malignant cerebral tumour. He was diagnosed in January 2020 …
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treatin…
35y · Female·multiple injuries sustained in fall from sixth-floor balcony
FJ, an Iranian woman with bipolar affective disorder and schizophrenia, died by suicide at age 35 in November 2016. Key clinical lessons include: (1) the critical importance of continuity of psychiatric care during trans…
55y · Male·exsanguination resulting from self-inflicted wounds to left brachial artery and …
Saxon George Hyatt, 55, died by suicide in Risdon Prison on 14 January 2019 through exsanguination from self-inflicted wounds to his brachial artery and wrists. He had a long history of mental health conditions including…
25y · Male·Multiple system failure and ingestion of sodium nitrite
BT, a 25-year-old man with bipolar affective disorder and long-standing depression, died from intentional sodium nitrite ingestion while an inpatient in the Behavioural Assessment Unit at Royal Melbourne Hospital. He pre…
41y · Female·Nitrate/nitrite toxicity
Jessinda Kiroyan, a 41-year-old woman with a longstanding history of bipolar affective disorder, died from nitrate/nitrite toxicity in May 2019 after intentionally ingesting sodium nitrite obtained from a food ingredient…
36y · Male·bronchial asthma
Nathan Reynolds, a 36-year-old Aboriginal man with severe asthma, died from bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease man…
26y · Male·Plastic bag asphyxia in the setting of a vitiated atmosphere with inert gases
Jack Watson, 26, died by intentional asphyxiation with inert gas on 2 August 2016. He had a long history of mental health issues including ADHD, depression and suicidal ideation. Following acute psychiatric admission to …
19y · Male·Multiple injuries sustained on a train impact (pedestrian)
Casey Evan Cahill, aged 19, died by suicide on 10 October 2019 when he placed himself in front of a train near Berwick Railway Station. He had a significant history of mental ill health including depression, psychotic sy…
2y · Male·traumatic head injury
A 2-year-7-month-old boy died from traumatic head injury inflicted by person(s) unknown after experiencing severe and escalating physical abuse over weeks. Despite 13 reports to FACS (now DCJ) between 2010-2012, includin…
49y · Male·Stab wound to the chest
A 49-year-old man with anxiety and depression died from a self-inflicted stab wound to the chest sustained during police response to a domestic violence call. He had brought tools and weapons to his ex-partner's home. Wh…
45y · Male·multiple drug toxicity
Robert Maxfield, a 45-year-old inmate at Cooma Correctional Centre, died from multiple drug toxicity involving methadone and mirtazapine. He had a history of drug dependence and mental health conditions (schizophrenia, d…
87y · Female·closed traumatic head injury from a fall at standing height; significant contrib…
An 87-year-old woman with dementia, congestive cardiac failure, and diabetes sustained a fatal closed head injury from a fall in her aged care room overnight. The coroner found that the responsible ECA did not perform th…
Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by…
Four inpatient suicides occurred at The Canberra Hospital mental health units between January 2015 and November 2016: three by hanging and one by jumping. The coroner found systemic failures including inadequate ligature…
22y · Male·Drowning
A 22-year-old university student with recent substance use presented to ED following violent behaviour. He had facial trauma with mild head injury and abnormal metabolic parameters. Initial management appropriately prior…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
65y · Male·Complications of end stage renal failure in a man with multiple co-morbidities
Mr Kermond, a 65-year-old man with intellectual disability, visual and hearing impairment living in a group home, was admitted to Lyndoch Living for respite care on 25 July 2019. He had end-stage renal failure and multip…
24y · Male·Gunshot wound to the head
A 24-year-old man with bipolar disorder and ADHD died by gunshot wound to the head approximately 5 months after a serious suicide attempt by overdose. He had been assessed as fit to hold a firearms licence by his treatin…
59y · Male·Disseminated carcinoma on a background of emphysema
Robert Fullerton, a 59-year-old Aboriginal man from Palm Island, died from disseminated carcinoma while remanded in custody at Townsville Correctional Centre. He presented with abdominal pain on 5 December 2018, was diag…
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