87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
54y · Female·Aspiration pneumonia secondary to Alzheimer's dementia complicating Down's Syndr…
Sandra Black, aged 54, died from aspiration pneumonia secondary to Alzheimer's dementia complicating Down Syndrome. She lived in specialist disability accommodation and had a long history of recurrent aspiration pneumoni…
90y · Female·Choking
A 90-year-old woman with dysphagia died from choking after consuming thin fluid (coffee) against medical recommendation. She had been reviewed by a speech pathologist on 15 November 2024 who recommended thick fluids only…
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
Male·Pulmonary thromboembolism and bronchopneumonia secondary to deep vein thrombosis
JNY, a man with metastatic small cell carcinoma, COPD, and ischaemic heart disease, died from pulmonary thromboembolism and bronchopneumonia. He received palliative care at home provided by his partner PJN, who had undis…
38y · Female·Multiple injuries sustained when struck by a train
Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…
25y · Male·Combined drug toxicity
Harrison William Ladd, 25, died from combined drug toxicity involving clonazepam, dexamphetamine, codeine, diazepam and pholcodine. He had complex mental health and substance use disorder requiring specialist addiction c…
31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)
A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …
45y · Male·Gunshot wounds to the head and left shoulder
Justin Filardo, aged 45, with a 28-year history of schizophrenia, was fatally shot by police after assaulting his sister Bianca in her bedroom. In the weeks prior, Justin had ceased his clozapine medication without clini…
61y · Male·Natural causes unascertained
David Evan Wild, 61 years old, died of natural causes of unascertained origin while residing in specialist disability accommodation. He had frontal temporal dementia diagnosed in 2020 and required 24/7 care. He experienc…
65y · Male·Metastatic disease with gastrointestinal primary (adenocarcinoma)
Ronald Nieuwenhuis, a 65-year-old man with intellectual disability residing in supported accommodation, presented to hospital in January 2025 with abdominal pain and was found to have metastatic adenocarcinoma of gastroi…
57y · Male·Neck compression and hanging
A 57-year-old man with schizophrenia and schizoaffective disorder died by hanging in prison on 4 August 2024. He had been receiving antipsychotic treatment via injection (paliperidone) but ceased antipsychotic medication…
52y · Male·Complications of chronic cardiac failure in the setting of ischaemic heart disea…
Sacha Timothee Louis Lefebvre, aged 52, died from complications of chronic cardiac failure with ischaemic heart disease and chronic anaemia whilst sleeping rough at Hawthorn Library. He had multiple chronic conditions in…
14y · Female·Drowning in a person with epilepsy
PCH, a 14-year-old girl in out-of-home care with a history of epilepsy, drowned in a river while washing her hair during a family camping trip. She had experienced increased seizure frequency in October-November 2024, pr…
74y · Female·Chronic obstructive pulmonary disease
Judith Gail Longhurst, a 74-year-old woman with cerebral palsy, dysphagia, and multiple comorbidities, died of chronic obstructive pulmonary disease (COPD) on 23 October 2024 at her Specialist Disability Accommodation re…
41y · Female·Mixed drug toxicity (alprazolam, clonazepam, diazepam, methadone, metoclopramide…
Catherine Lynch, a 41-year-old nurse, died from mixed drug toxicity in July 2022 in circumstances consistent with suicide. She was experiencing severe family violence, including coercive control, threats, stalking and em…
63y · Male·Effects of fire
A 63-year-old man with bipolar disorder, Crohn's disease, ADHD and HIV died in a residential fire at his apartment. He was found with evidence of unsafe smoking in bed, including numerous cigarette butts throughout his u…
74y · Female·Acute renal failure complicating decreased oral intake in the setting of Angelma…
Susan June Mahoney, a 74-year-old woman with Angelman syndrome, died from acute renal failure secondary to progressively declining oral intake. From April 2025, staff observed reduced food and fluid intake with swallowin…
31y · Male·Aspiration pneumonia in a man with intellectual disability and epilepsy (palliat…
Cameron James Stewart, a 31-year-old man with severe cerebral palsy, intellectual disability, epilepsy, and dysphagia, died of aspiration pneumonia at Maroondah Hospital. Following a COVID-19 infection in December 2023, …
53y · Female·Unascertained (presumed drowned)
Kathleen Smith, a 53-year-old podiatrist, disappeared on 15 July 2024 and is presumed to have drowned at Sorrento Back Beach. She was experiencing severe anxiety about upcoming foot surgery due to severe flatfoot deformi…
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