1,963 results
53y · Male·Acute subdural haemorrhage
David Waghorn, aged 53, died from acute subdural haemorrhage following a fall or head strike on 16 April 2007. He had opiate dependence and was under the influence of drugs at the time of the incident. He fell or stumble…
32y · Female·Opiate toxicity; toxic combination of morphine and codeine causing respiratory d…
Mrs Edwards, a 32-year-old woman with severe depression and psychiatric history, was found dead in bed. Autopsy revealed opiate toxicity with high levels of morphine and codeine. Toxicology expert opinion indicated morph…
45y · Male·overdose of quetiapine (Seroquel) augmented by alcohol
A 45-year-old man with schizophrenia and a decade-long history of repeated overdoses died from quetiapine (Seroquel) toxicity combined with alcohol. Critical failures occurred: multiple doctors prescribed large quantitie…
44y · Female·mixed drug toxicity with aspiration of gastric contents
A 44-year-old woman with chronic back pain and depression died from mixed drug toxicity with aspiration of gastric contents. She had been prescribed multiple medications including amitriptyline, diazepam, codeine, and lo…
8y · Male·bacterial meningitis that had not been diagnosed by a number of clinicians who h…
Eight-year-old Isaraelu Pele died of bacterial meningitis missed by multiple clinicians despite three hospital presentations and two GP visits between 14–17 December 2007. Critical failures included: inadequate different…
47y · Female·insulin overdose
Katherine Walton, a 47-year-old registered nurse, died from insulin overdose in April 2007. She had a complex medical history including hepatitis C, depression, chronic back pain, epilepsy, and substance use issues. Afte…
38y · Female·unascertained, likely natural causes
Dianne Rose Guthrie, a 38-year-old woman with intellectual disability secondary to childhood head injury and myotonic dystrophy, died at a residential disability facility. She was found unresponsive on 5 March 2009 and r…
63y · Male·Metastatic carcinoma of the lung
Lawrence Jeffrey, a 63-year-old inmate at Lotus Glen Correctional Centre, died from metastatic lung carcinoma on 11 May 2008. He presented with symptoms consistent with his known chronic conditions (asthma, COPD, silicos…
31y · Male·Combined effects of multiple drugs in an obese male with findings suggestive of …
Simon Mark Gray, a 31-year-old man, died from combined effects of multiple medications in the setting of obesity and bronchopneumonia, less than 24 hours after discharge from psychiatric hospital. He had suffered a workp…
44y · Male·pneumonia and possible large left cerebrovascular accident (stroke) in a man wit…
Jamie Alan White, a 44-year-old man with neurofibromatosis, paraplegia, sleep apnoea, and chronic respiratory issues, was found unresponsive in his residential care unit bed on 15 June 2008 and could not be revived. The …
20y · Female·food-induced anaphylaxis, likely to peanut allergen
Kylie Lynch, a 20-year-old woman with chronic asthma and a known peanut allergy, died from anaphylaxis on 2 September 2007 in Coral Bay, Western Australia. She consumed desserts at Fin's Café after dining at a nearby hot…
95y · Male·bronchopneumonia in a man who has sustained extensive head injury
A 95-year-old man with multiple comorbidities including ischaemic heart disease, atrial fibrillation, chronic airways disease, aspiration pneumonia history, and dementia was struck unprovoked by a cognitively impaired co…
45y · Male·unascertained
Mark Anthony Theakston, a 45-year-old man with severe intellectual disability and autism residing in supported accommodation, died of an unascertained cause on 25 May 2008. He had collapsed on 21 May with a syncopal epis…
49y · Female·Multi organ failure and Pneumonia
Sharon Ann Looby, a 49-year-old woman with Down's syndrome, presented with symptoms of malaise, sweats, cough and bloating. Her general practitioner arranged blood tests which revealed renal impairment and liver inflamma…
29y · Female·Invasive aspergillosis
A 29-year-old registered nurse with systemic lupus erythematosus (SLE) died from invasive aspergillosis. Dr G. prescribed lamotrigine 100 mg daily (double the recommended initial dose of 50 mg) on first consultation with…
51y · Male·Cardiac arrest due to ischaemic heart disease
Andrew Campbell, a 51-year-old disability pensioner with multiple serious medical conditions (Type 1 diabetes, ischaemic heart disease, hypertension), died of cardiac arrest on 16 July 2008, six days after moving into pu…
31y · Male·Hanging
Mustapha Hayek, aged 31, died by hanging at his home on 16 December 2007. He was found by police conducting a welfare check at his partner's request after the couple had argued four days earlier. The coroner found he too…
37y · Female·Unascertained
Fiona McBurney, 37, with Down syndrome, intellectual disability, Type 1 diabetes, and epilepsy, died at Helen Schutt House, a residential care facility, in June 2009. She was found deceased by care staff the morning afte…
42y · Male·incised wound to the neck
Wesley Robert Jennings, a 42-year-old male with long-standing depression, anxiety, hepatitis C and substance use history, died by suicide by incised neck wound whilst on remand in prison. The coroner found no demonstrabl…
34y · Male·Hypoxic-ischaemic brain injury caused by hanging
Craig Stevens, aged 34, died from hypoxic-ischaemic brain injury following a suicide by hanging on 17 June 2008. Despite police intervention, critical delays in cutting the ligature around his neck prevented timely resus…
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