20y · Female·Aspiration of sand; cause of sand aspiration not determined
…nical gaps included failure to obtain toxicology samples, forensic swabs, or alcohol testing at the first autopsy in Mozambique—the optimal time for such testing. The Mozambique autopsy was technically suboptimal, with …
49y · Male·Undetermined
…otion to his children argued against this. The coroner found no suspicious circumstances. Critically, the autopsy performed by Dr R., a non-specialist, was severely inadequate. It failed to follow NSW Health Policy Guid…
20y · Male·massive basal subarachnoid haemorrhage caused by a blow to the head
…inical lesson is that neuropathologists reviewing this case noted the absence of aneurysmal dilatation on autopsy, which is unusual in spontaneous aneurysm rupture. The original pathologist may have misinterpreted the f…
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 mo…
61y · Male·Multiple injuries (head, spinal, trunk, pelvic and limb) sustained in a motor ve…
…ming truck. The most likely cause was a medical event (he was found to be obese with an enlarged heart at autopsy) or that he fell asleep. Road and vehicle conditions were appropriate, neither driver was speeding or usi…
…ase highlights the importance of explicit family consent for any retention of body parts, transparency in autopsy practices, and proper governance of pathology specimens.
0y · Unknown·Unascertained
…multiple illicit drugs (MDMA, methamphetamine, cannabis, tramadol) but no evidence these caused death. An autopsy was not performed due to parental objection. Clinical lessons include the importance of safe sleep practi…
Female·undetermined
…rmine either the cause or manner of death due to insufficient evidence. The critical finding was that the autopsy procedure was hindered by inadequate collection and storage of biological specimens essential for forensi…
48y · Male·Undetermined
…endence Unit provided minimal monitoring despite prescribed doses increasing fourfold over 2.5 years. The autopsy was seriously deficient, performed by a general practitioner insufficiently trained in complex cases, wit…
64y · Male·undetermined due to advanced decomposition
… died alone at home between May and July 2015. He was found in an advanced state of decomposition, making autopsy inconclusive. A bladder tumour had been identified by his GP in January 2015, but he refused hospital adm…
47y · Female·unascertained - natural causes
…ush regeneration worker, was found deceased in bed on Christmas Day 2014. Despite a thorough three-cavity autopsy and comprehensive investigations including microscopic tissue examination, toxicology, and biochemical an…
66y · Female·Drowning
…6 mg/100ml) and under the influence of multiple drugs including diazepam, tramadol, and propoxyphene. The autopsy initially raised concerns as her lungs contained less water than typically seen in drowning deaths, promp…
63y · Female·Unascertained (natural causes) - favoured mechanism sudden cardiac arrhythmia
…ility accommodation, was found unresponsive in the toilet and declared deceased at 7:32pm on 13 May 2022. Autopsy revealed severe fatty liver disease, elevated heart weight, and foreign material in airways, with sudden …
Male·unknown
… could not be established. The remains appear consistent with traditional Aboriginal burial practices. An autopsy had previously been performed on the deceased. Despite DNA analysis attempts, no definitive identificatio…
67y · Male·respiratory failure with antecedent causes including chronic emphysematic lung d…
…ped in the chest wall. He subsequently developed respiratory infection and died from respiratory failure. Autopsy revealed no cancer cells in the original biopsy sample—a diagnostic error. Key lessons: A quality assuran…
43y · Male·Undetermined — available evidence does not allow determination due to limitation…
…tem examination and fire investigation, the coroner could not determine the cause or manner of death. The autopsy was critically inadequate: organs were not removed or weighed, no radiological imaging was performed, and…
14y · Male·Undetermined; high suspicion of non-accidental injury, most likely smothering, b…
Vaughan Murray, a 14-week-old infant, died at Ipswich General Hospital with an undetermined cause despite autopsy findings highly suggestive of non-accidental injury. He had five partially healed rib fractures (3-6 week…
62y · Female·Unknown. Likely natural causes, possibly with drug-related element. QT-prolongat…
…se disorder (heroin, cannabis, methadone). She was last seen on 27 February appearing unwell and pale. An autopsy revealed no clear cause of death due to advanced decomposition, though toxicological testing showed eleva…
66y · Male·Acute myocardial infarction
…oung, aged 66, died of acute myocardial infarction while a resident in Department of Human Services care. Autopsy revealed significant coronary artery disease with a clot in a major coronary artery causing a recent hear…
86y · Female·Unable to be determined
…rly given her significant pre-existing ischaemic heart disease and heart failure. However, without a full autopsy, the actual cause could not be determined. The coroner found no evidence of direct intervention. Key clin…
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