56 results
18y · Male·drowning in a motor vehicle accident
MK, 18 years old, died by drowning after his car entered Isabella Pond following a motor vehicle accident. Witnesses observed him inhaling from a balloon-shaped object while driving through a roundabout. A large nitrous …
62y · Male·cardiac arrest caused by hypothermia following prolonged exposure to extreme col…
Captain David Wood, an experienced helicopter pilot, fell into a concealed crevasse on the West Ice Shelf in Antarctica while conducting fuel cache operations. He was exposed to extreme cold (-14°C) and remained in the c…
19y · Female·multiple injuries sustained in a motor vehicle collision
A 19-year-old woman died from multiple injuries sustained in a motor vehicle collision on Black Mountain Drive, Canberra on 4 June 2022. She was driving a 1986 Toyota sedan at approximately 80 km/h when she lost control …
40y · Male·hypothermia
Nathan Booth, a 40-year-old Aboriginal man with opioid addiction, was reported missing on 2 September 2019 after last being seen on 27 June 2019 when he obtained his methadone dose at Canberra Hospital. His body was foun…
69y · Male·thoracic aortic aneurysm with dissection
Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…
43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…
A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
34y · Female·multiple drug toxicity
Katherine Alexander, a 34-year-old woman with chronic suicidality and complex mental health conditions including bipolar II disorder, borderline personality disorder, and PTSD, died from multiple drug toxicity on 7-8 Feb…
39y · Female·multiple drug toxicity (etizolam and carisoprodol as major components)
Catherine Broadbent, 39, died from multiple drug toxicity involving benzodiazepines (etizolam, carisoprodol) sourced from the dark web, in the context of chronic borderline personality disorder and complex PTSD with life…
23y · Male·Drowning
Najeebullah Rafee, a 23-year-old ANU international relations student and Afghan refugee, drowned on 25 October 2020 at Cotter Bend, a promoted ACT river recreation area. A non-swimmer, he attempted to use a small flotati…
43y · Female·Complications of morbid obesity, including progressive respiratory and cardiac f…
Nicole Abbott, 43, died from complications of morbid obesity (BMI 54.4) including progressive respiratory and cardiac failure, exacerbated by smoking and obstructive sleep apnoea. She was subject to a Psychiatric Treatme…
90y · Female·acute bronchopneumonia caused by Staphylococcus aureus
Ruth McKay, 90, died of acute bronchopneumonia after accessing the external courtyard of the Memory Support Unit (MSU) at an aged care facility undetected in the early morning of 17 January 2015. She was found under a st…
17y · Male·Circulatory failure caused by traumatic brain injury from being struck by a log
Christiaan Adriaan Roodt, a 17-year-old Year 10 student, died from traumatic brain injury when struck by a 6-metre log during a 'Capture The Flag' game at Mount Ainslie, near his school. Key clinical lessons: (1) The ina…
23y · Female·Hypoxic-ischaemic brain damage due to self-inflicted hanging with intention of t…
Brontë Haskins, aged 23, died by suicide via hanging on 18 February 2020, three days after her release from custody on bail. The inquest identified multiple systemic failures in supervision, assessment, and coordination …
79y · Female·medication related cardiac arrest (verapamil and propranolol) in a patient with …
Mrs Patricia Croxon, a 79-year-old admitted with community-acquired pneumonia, died from medication-related cardiac arrest caused by verapamil and propranolol. The verapamil was charted in immediate release form when she…
18y · Male·asphyxia by hanging; intentional self-harm
Joshua, 18, died by suicide at an ANU residential hall in August 2018, several weeks after a serious self-harm incident requiring hospitalisation. Key clinical lessons emerge: (1) Inadequate coordination between ACT Ment…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…
72y · Female·subdural haemorrhage sustained from a fall from a hospital bed on 18 January 201…
Mrs Judith Gaye Flynn, aged 72, died from a subdural haemorrhage sustained when she fell from a hospital bed on the General Medicine Ward at Canberra Hospital. She was a high-risk fall patient with cognitive impairment, …
25y · Male·Cardiorespiratory arrest due to aspiration pneumonia and hypoxic-ischaemic encep…
Dean Brice, aged 25, died from accidental multiple drug toxicity (methamphetamine and GHB) causing cardiorespiratory arrest, aspiration pneumonia and hypoxic-ischaemic encephalopathy. He was subject to a Psychiatric Trea…
9y · Male·Traumatic head injury with diffuse cerebral swelling and subdural haemorrhage ca…
Bradyn Dillon, aged 9, was brutally beaten to death by his father Graham Dillon in February 2016. The inquest examined how multiple agencies—police, child protection, education, and health services—failed to protect him …
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