62y · Male·head, chest and pelvic injuries sustained in a cycle versus car motor vehicle in…
Jon Gorr, aged 62, died from head, chest and pelvic injuries sustained in a collision between his bicycle and a car driven by William Bennett on Tooram Road, Allansford, Victoria on 28 September 2021. The coroner was una…
51y · Male·Stab wounds to the chest
A 51-year-old man with documented mental health issues including psychosis, paranoia, and delusions died from self-inflicted stab wounds during a police siege at his mother's home. He had breached a domestic violence ord…
2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…
A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…
33y · Male·Contact range shotgun injury to the head
A 33-year-old man died from a contact range shotgun injury to the head while subject to a Mental Health Act apprehension order. Police conducted a six-hour operation involving 120 members across multiple units after he p…
52y · Male·hanging
A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He had requested a CPAP machine for over 9 months without receiving one, which he be…
68y · Male·chest, spine, pelvic and limb injuries sustained in a two vehicle motor vehicle …
Graham Seth Wells, aged 68, died from chest, spine, pelvic and limb injuries sustained in a two-vehicle motor vehicle collision on the Bass Highway, Latrobe, Tasmania on 22 October 2022. Mr Wells was driving a Ford Focus…
1y · Male·hypoxic brain damage due to laryngeal obstruction from foreign body (metal screw…
An 11-month-old boy died from hypoxic brain damage following aspiration of a 2cm metal screw that lodged in his larynx. The child was left briefly unsupervised at home when he ingested the screw and began choking. Parent…
58y · Male·acute bronchopneumonia
Giovanni Trotta, aged 58, died in custody from acute bronchopneumonia. He was a vulnerable prisoner with COPD, schizoaffective disorder, and profound deafness. Clinical lessons include: (1) hospital discharge summaries m…
7y · Female·Pneumonia complicating a viral respiratory illness with acute combined drug effe…
Child ML, aged 7, died of pneumonia complicating viral respiratory illness with acute combined drug effect. She had severe cerebral palsy with complex care needs including PEJ tube feeding and multiple medications. At th…
61y · Male·congestive cardiac failure due to cardiomegaly with left ventricular hypertrophy
A 61-year-old man with diabetes, obesity, and high cholesterol presented to his GP with shortness of breath for 4-5 days and tachycardia (HR 120). The GP diagnosed anxiety instead of cardiac failure, failed to ask critic…
46y · Male·injuries sustained in a motorcycle incident (rider)
A 46-year-old experienced motorcycle rider died following a collision on the Western Ring Road when he attempted to overtake a truck on an exit ramp. The rider misjudged the available distance and struck a traffic island…
61y · Male·Complications of multiple system atrophy
Gary Nicholls, aged 61, died from complications of multiple system atrophy while residing in specialist disability accommodation after only three days. He had recently transitioned from aged care following approval of an…
4y · Female·Drowning
A 4-year-old girl from an Afghan refugee family drowned in Lysterfield Lake after entering the water during a brief lapse of supervision. She was unable to swim and had not received water safety education. Despite immedi…
55y · Female·smoke inhalation from domestic fire caused by unextinguished cigarette
A 55-year-old woman with a prior stroke causing physical disability, intellectual disability, schizophrenia, epilepsy, diabetes and atrial fibrillation died from smoke inhalation in a domestic fire. She was a heavy smoke…
27y · Male·multiple blunt force injuries
A 27-year-old Colombian national died by suicide four days after arriving in Australia. He had disclosed suicidal ideation to his friend and family on 24 November, was recovered from a cliff edge that evening, but died t…
26y · Male·acute cocaine and alcohol toxicity
AAB, a 26-year-old man with a history of substance abuse and mental health issues, died from acute cocaine and alcohol toxicity while in police custody. He presented to a hotel with agitated, paranoid behaviour and was d…
48y · Male·unascertained
Abdurahman Faid, a 48-year-old man with chronic schizophrenia and acquired brain injury from cerebral malaria, died unexpectedly in hospital on 31 December 2018 while an involuntary psychiatric patient. He had untreated …
64y · Female·head injury sustained in a single motor vehicle accident
Mrs Alyson Margaret Mellor, aged 64, died from a head injury sustained in a single-vehicle motor accident on 30 April 2022. She had type 1 diabetes managed with an insulin pump, and on the day of the accident her husband…
72y · Male·Upper cervical spine injury sustained in a fall from a ladder
A 72-year-old man suffered a fall from a 3-metre ladder during home garden maintenance, sustaining a severe upper cervical spine injury (C2 fracture with high spinal cord haemorrhage) that was deemed non-survivable. He d…
66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…
Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arteriosclerotic cardiovascular disease, pulmonary thromboembolism, and metasta…
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