16y · Female·hanging
…t ('chrome') use and relationship breakdown. She had chronic substance abuse, complex psychosocial needs, learning difficulties, and disengagement from education. While Child Protection workers were conscientious and mad…
62y · Male·drowning/immersion due to multiple drug intoxication (methamphetamine, diazepam,…
…is), coronary artery disease and obesity. The coroner identified multiple contributing factors: vehicle difficulties making him anxious to leave, heavy rain impairing visibility and hearing, darkness, and cognitive impai…
17y · Male·Unascertained in the setting of volatile substance abuse
…uicidal ideation expressed repeatedly in 2016-2017 was not comprehensively assessed by mental health; (4) learning difficulties and possible intellectual disability were documented but never formally assessed or accommod…
18y · Male·Multiple injuries due to train over-run
Charles Ross Maxwell Morgan, an 18-year-old Aboriginal man, died when struck by a train near Zillmere Railway Station in January 2012. He was moderately intoxicated with alcohol and cannabis, with recent cannabis use. Th…
51y · Male·Exsanguination during home haemodialysis in a man with end stage renal failure
… stronger safeguards for home use. Better scene preservation at medical emergencies is also important for learning from such events.
39y · Male·Infective endocarditis, with intravenous drug use as a contributing factor
…sed by Streptococcus anginosus. The coroner found the quality of medical care was thorough and sound. Key learning points include the importance of contacting next of kin when patients with mental illness are admitted, a…
23y · Female·Death by homicide; medical cause unable to be determined due to body not being l…
Krystal Lee Fraser, 23 years old and nine months pregnant, disappeared from Pyramid Hill, Victoria on 20 June 2009 and has never been found. The coroner concluded she died on or shortly after 21 June 2009 near Leitchvill…
7y · Male·Blunt force head injury with bilateral acute subdural haemorrhage, hypoxic/ischa…
Levai, a 7-year-old boy with learning difficulties, died from blunt force head trauma inflicted by his mother's boyfriend Kodi Maybir on 20 May…
81y · Female·Aspiration pneumonia in an elderly lady
An 81-year-old woman with intellectual disability, phenylketonuria, and severe dysphagia died from aspiration pneumonia following repeated admissions for the same condition. She had been assessed as 'very high risk of as…
29y · Female·hanging
A 29-year-old international medical graduate student from Bangladesh died by hanging in July 2020. She was studying a Master of Public Health at Deakin University but had failed multiple units and was struggling academic…
56y · Male·Complications of atraumatic bilateral femoral fractures (repaired) during a seiz…
Mark O'Brien, a 56-year-old man with Down syndrome and dementia, sustained multiple seizure-related bilateral femoral fractures. A subtle posterior cortical fracture to his left femur, sustained during a seizure on 15 Ju…
31y · Male·Burns
31-year-old George Grimes with longstanding schizophrenia was found threatening self-immolation after consuming alcohol and missing antipsychotic medication. Despite police de-escalation attempts, he doused himself with …
58y · Male·asphyxiation by ligature
A 58-year-old Cambodian male with basic English skills died by suicide in prison after 7 days in custody on remand for assault. Critical failures in the reception screening process included: incomplete identification and…
37y · Male·Coronary artery thrombosis resulting from coronary atherosclerosis with contribu…
…bulance crew directly contributed to death, their failure denied timely emergency medical assessment. Key learning: paramedics must transport patients with unexplained chest pain for emergency assessment rather than acti…
31y · Male·hanging
Mr Gavin Ellis, 31 years old, died by hanging in custody on 2 April 2017 at the Metropolitan Remand and Reception Centre, Silverwater. He had a chronic treatment-resistant schizophrenic illness with extensive self-harm h…
2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …
BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…
54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking
A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to…
smoke inhalation and burns from deliberately-lit fire (primary cause varies by i…
Fourteen elderly residents died in a deliberately-lit fire at Quakers Hill Nursing Home on 18 November 2011, set by drug-dependent nurse Roger Dean to destroy evidence of medication theft. Dean had worked while visibly i…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.