218 results
86y · Male·ischaemic and hypertensive heart disease
An 86-year-old man died of ischaemic and hypertensive heart disease while serving a prison sentence. He had multiple comorbidities including atrial fibrillation, congestive cardiac failure, and cirrhosis. The coroner exa…
Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…
Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…
44y · Male·unascertained
Matthew Benjamin Holding, aged 44, died suddenly in prison on 2 January 2023. He had schizophrenia managed with antipsychotics and severe obesity (BMI 41.6). In December 2022, he showed signs of significant deterioration…
79y · Male·Urinary tract infection with E coli bacteraemia on a background of ischaemic hyp…
A 79-year-old man with multiple comorbidities attended Whyalla Hospital ED following a fall. Paramedics documented concerning vital signs (tachypnoea, tachycardia, low oxygen saturation, fever) and a history suggestive o…
88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…
An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatra…
27y · Male·heroin toxicity
A 27-year-old man died from heroin toxicity while on home detention bail. He had a history of depression, anxiety, and substance use (cannabis, methamphetamine, heroin). During home detention, he was compliant, engaged w…
25y · Male·hanging
Logan Brown, a 25-year-old man on home detention bail, died by hanging. He had a complex psychiatric history including borderline personality disorder, polysubstance use disorder, and chronic suicidal ideation dating fro…
36y · Male·acute neck compression due to hanging
Paul Douglas Gifford, aged 36, died by hanging while on home detention bail. He had a long history of substance abuse (methamphetamine, opioids), mental health issues including borderline personality disorder, childhood …
66y · Male·multiple injuries sustained in motor vehicle collision
A 66-year-old cyclist was struck and killed from behind by a driver with left absolute homonymous hemianopia (left-sided visual field loss) who was not scanning to compensate for his disability. The driver had suffered a…
89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…
An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…
80y · Female·Fractured left neck of femur on a background of rectal carcinoma and dementia
An 80-year-old woman with dementia and undiagnosed rectal carcinoma died from complications of a fractured left neck of femur sustained during a fall in her aged care facility's memory support unit. She had sustained thr…
48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam
A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…
43y · Male·methylamphetamine and heroin toxicity
A 43-year-old man died from methylamphetamine and heroin toxicity while on home detention bail. He had a complex psychiatric history including depression, psychosis, PTSD, and polysubstance use disorder, with previous su…
35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…
35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…
18y · Male·compression of the neck in keeping with hanging
An 18-year-old Aboriginal man died by hanging three days after release from prison on home detention bail. He had been displaying acute psychotic symptoms while in prison custody, placed under camera observation due to s…
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…
20y · Male·gunshot wound to the chest
A 20-year-old man with borderline personality disorder, who had made over 25 suicide attempts in the two years prior, died from a gunshot wound sustained during a police encounter. He had called mental health services an…
23y · Female·stab wound of the chest
Kunmanara May, aged 23, was killed by her partner SK in a domestic violence homicide in 2015. Multiple agencies—South Australia Police, Families SA, Aboriginal Family Support Service, and Centacare—knew of escalating vio…
59y · Male·inhalation of products of combustion and effects of heat
Peter Howard, 59, a 27-year Orora packaging factory employee, died from inhalation of combustion products when his car caught fire outside the Athol Park site on 28 August 2018. After a workplace altercation with colleag…
0y · Male·unascertained, in an unsafe sleeping environment, on a background of respiratory…
Baby Caleb, aged 2 months, died on 30 November 2018 in an unsafe sleeping environment while his mother co-slept with him on a fold-out sofa in a squalid home. He had a concurrent respiratory tract infection. The coroner …
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