1,963 results
47y · Female·risperidone toxicity
Rosa Sinapi, a 47-year-old woman with delusional disorder, died from risperidone toxicity after ingesting an overdose of her antipsychotic medication. She had self-escalated her risperidone dose from 3mg to 6mg daily wit…
26y · Male·self-inflicted gunshot wound to the head while suffering severe depression
Morgan Hill, a 26-year-old NSW police officer, died by self-inflicted gunshot wound in March 2009 while severely depressed. Over 20 months prior to death, he experienced escalating mental health difficulties with work ab…
49y · Female·aspiration pneumonia complicating cerebral palsy
Ms Sheryl Yvonne Martell, a 49-year-old woman with cerebral palsy and severe intellectual disability residing in a group home, died from aspiration pneumonia. She was admitted to hospital on 21 June 2010 after vomiting a…
50y · Female·compression of the neck consistent with hanging
Yan Yi Xu, a 50-year-old woman with a history of depression and recent breast cancer diagnosis, was admitted to Cramond Clinic psychiatric ward following a suicide attempt on Christmas Day 2008. She died by hanging in he…
75y · Male·Gunshot wound to the head
Luciano T, a 75-year-old man with complex medical and psychiatric history including chronic pain, depression, and delusional jealousy syndrome, shot his wife in the face and then fatally shot himself. He had been under p…
8y · Male·Septic shock consequent on burst appendix with peritonitis
Jacob Belim, aged 8, presented to a GP with appendicitis on 24 March 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Li…
41y · Male·Neck compression subsequent upon hanging
A 41-year-old man with depression, anxiety and prior suicidal ideation died by hanging on the morning of a scheduled psychology appointment. He had been referred by his GP for psychiatric care five days prior following a…
91y · Female·pulmonary thromboembolism and subcutaneous abscess formation complicating pressu…
A 91-year-old woman died from pulmonary thromboembolism and abscess formation complicating untreated ankle fracture and pressure sores. She had sustained a fracture-dislocation of her right ankle after a fall, which she …
41y · Female·Hanging
Patricia Webster, a 41-year-old with a history of major depressive disorder, was admitted to hospital on 8 October 2009 after stopping antidepressants. She was discharged on 21 October with community mental health follow…
63y · Male·cerebral infarction
John Arthur Burns, a 63-year-old man with frontotemporal dementia and motor neurone disease, died from cerebral infarction on 17 September 2006 while in Westminster Aged Care Facility after only 12 days of residence. Des…
60y · Male·cardiorespiratory failure due to malignant pleural effusion due to metastatic ma…
A 60-year-old man with diabetes presented with a plantar heel ulcer in March 2007 that was initially treated as a diabetic foot ulcer. The lesion failed to heal over 16 months despite standard care including wound dressi…
64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…
Marlene Kenny, 64, presented to Orbost Hospital on 8 January 2007 with chest tightness, breathing difficulties and low oxygen saturation (83-86%). A doctor diagnosed panic attack and discharged her without investigation.…
15y · Male·multiple blunt force injuries as a result of being hit by a train
AB, a 15-year-old boy with depression and suicidal ideation, was prescribed Lexapro (escitalopram) by his GP despite it not being registered for use in adolescents. The coroner identified significant failures in clinical…
40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…
Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…
28y · Female·bronchopneumonia complicating oxycodone toxicity
Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropri…
39y · Male·COMPLICATIONS OF CHRONIC RENAL FAILURE
Drew Aaron Boaler, a 39-year-old man with severe intellectual disability, epilepsy, bipolar disorder, and chronic renal failure, died from complications of his renal disease while on an outing. He had presumed lithium-in…
62y · Female·Ischaemic heart disease secondary to diabetes
Margaret Jones, a 62-year-old woman with Smith-Magenis syndrome, intellectual disability, diabetes, and cardiomegaly, died of ischaemic heart disease. She presented to her GP on 23 October 2008 with six weeks of flu-like…
62y · Male·Extensive liver tumour, primary site not identified
James Williams, a 62-year-old man with intellectual disability, presented to his GP with tiredness, anorexia and fever. Initial assessment suggested possible hepatitis and he was referred to hospital. CT imaging revealed…
65y · Female·Ischaemic heart disease (coronary artery atherosclerosis); probable cardiac arrh…
Dorothy Plumb, a 65-year-old woman with intellectual disability living in a residential unit, was found unresponsive in bed and pronounced dead. Autopsy revealed significant coronary artery atherosclerosis with triple ve…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.