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NThospital2026-01-09

Inquest into the death of C Guyula

49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …

A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical fa…

anaesthesiasurgeryproceduralmedicationfentanyl
NThospital2025-12-19

Inquest into the death of T. Ptjara and T. Ptjara

Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…

Two Aboriginal brothers with chronic alcohol use disorder and cognitive impairment died in July and September 2023 in Alice Springs Hospital. Both had adult guardianship orders, NDIS packages, and aged care assessments r…

emergency medicineintensive carecommunicationsystem
NTPodcast2025-10-24

Inquest into the death of Ebony Thompson

1y · Female·hypoxic brain injury caused by pressure to the neck from entrapment on a loop-to…

Ebony Thompson, aged 22 months, died from hypoxic brain injury caused by neck entrapment in a loop-topped chickencoop gate at a childcare centre. She became trapped while standing on a tricycle attempting to view chicken…

paediatricsemergency medicinesystemcommunication
NT2025-08-29

Inquest into the death of Raylene Dick, David Hardy and Karen Bading

46y · Female·Hepatic encephalopathy due to decompensated Child-Pugh C cirrhosis and meningiti…

This combined coronial finding examines three deaths at the Centre for National Resilience (CNR), a COVID-19 quarantine facility in Howard Springs. Ms Dick died from rapidly progressive melioidosis. David Hardy died from…

infectious diseasesintensive carediagnosticsystem
NThospital2025-03-25

Inquest into the death of Judith Smart

66y · Female·Hypoxic-ischaemic encephalopathy

A 66-year-old woman with COPD, obstructive sleep apnoea, and obesity underwent routine knee surgery at Royal Darwin Hospital. Post-operative care was inadequate. Despite dropping oxygen saturations to 88% when sedated an…

anaesthesiaorthopaedic surgerydiagnosticsystemmorphine
NTmental health2025-02-14

Inquest into the death of Pukumani

47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…

Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…

psychiatryemergency medicinediagnosticcommunicationketamine
NThospital2025-01-10

Inquest into the death of Mati Tamwoy

66y · Male·infectious complications of plasmablastic myeloma

Mati Tamwoy, a 66-year-old Aboriginal man, died in ICU from infectious complications of plasmablastic myeloma after 661 days on remand. He received excellent oncological care including chemotherapy and radiotherapy. Howe…

haematologyoncologysystemcommunicationchemotherapy agents
NThospital2024

Inquest into the death of Road Death 60 of 2024

74y · Male·Complications of multiple blunt force injuries sustained in a motor vehicle cras…

A 74-year-old Aboriginal man died from complications of multiple blunt force injuries sustained in a single-vehicle rollover crash on Christmas Day 2024. He was driving with a blood alcohol concentration of 0.14% (three …

trauma surgeryintensive carealcohol
NThospital2024

Inquest into the death of Road Death 27 of 2024

39y · Male·Multiple blunt force injuries due to motor vehicle collision (pedestrian), with …

A 39-year-old Aboriginal male with chronic alcohol intoxication was struck by a vehicle travelling at 79 km/h in a 60 km/h zone while crossing unsafely at an uncontrolled location. He sustained severe traumatic brain inj…

neurosurgerytrauma surgeryalcohol
NThospital2024

Inquest into the death of Road Death 35 of 2024

20y · Female·Severe traumatic brain injury sustained in a pedestrian versus motor vehicle col…

A 20-year-old Aboriginal female pedestrian with bilateral hearing loss was struck by a vehicle driven by an intoxicated male driver (BAC 0.158%) travelling at 74 kph in a 60 kph zone. She suffered catastrophic traumatic …

emergency medicineneurosurgery
NThospital2024

Inquest into the death of Road Death 45 of 2024

51y · Male·Spontaneous intracerebral haemorrhage

A 51-year-old Aboriginal man experienced a spontaneous intracerebral haemorrhage while riding his motorcycle, causing him to crash. He was transported to Alice Springs Hospital where he remained on life support in ICU fo…

neurosurgeryintensive care
NThospital2024

Inquest into the death of Road Death 51 of 2024

59y · Female·Complications of blunt force chest injuries with clinically diagnosed Pseudomona…

A 59-year-old woman with Child Pugh C liver cirrhosis and COPD suffered a single-vehicle crash on 15 October 2024 after losing control of her vehicle at a caravan park entrance. She had a blood alcohol level of 0.096% (m…

emergency medicineintensive carealcohol
NThospital2024

Inquest into the death of Road Death 32 of 2024

78y · Female·Blunt force chest injuries from motor vehicle crash, compounded by chronic obstr…

A 78-year-old Aboriginal woman died from blunt force chest injuries sustained as a passenger in a single-vehicle run-off crash on a remote road in the Northern Territory. She was wearing a seatbelt and the crash was low-…

emergency medicineintensive care
NThospital2024

Inquest into the death of Road Death 19 of 2024

22y · Female·Traumatic brain injury (diffuse axonal injury with skull fractures) secondary to…

A 22-year-old female died from traumatic brain injury sustained in a single-vehicle rollover on a rural road in the Northern Territory. She had consumed 15-20 cans of beer over approximately 10 hours, achieving a blood a…

trauma surgeryneurosurgeryalcohol
NThospital

Inquest into the death of Road Death 53 of 2024

49y · Female·Blunt force head injury from pedestrian-pushbike collision

A 49-year-old woman died from catastrophic head injuries sustained in a pedestrian-bicycle collision on a footpath in Darwin. She exited a gate with obscured visibility and stepped directly into the path of a 12-year-old…

neurosurgeryintensive care
NThospital2020-07-17

Inquest into the death of Ishmael Nawirridj

51y · Male·Multiple organ failure due to Influenza A pneumonia, in the context of chronic k…

Ishmael Nalaiyir Nangarid, a 51-year-old Aboriginal man with complex medical history including myasthenia gravis, chronic kidney disease, COPD, and ischaemic heart disease, died from multiple organ failure due to Influen…

intensive carerespiratory medicinemedicationmeropenem
NThospital2019-09-20

Inquest into the death of Joanne Craig

57y · Female·multi-organ failure due to sepsis caused by streptococcus pneumoniae infection

Joanne Craig, a 57-year-old Aboriginal woman, presented to Katherine District Hospital on 24 January 2018 with fever, vomiting, and cough. She had streptococcus pneumoniae sepsis with elevated inflammatory markers from 1…

emergency medicinegeneral practicediagnosticcommunicationondansetron
NThospital2019-04-16

Inquest into the death of Ali Achmadun Djawas

70y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …

Ali Djawas, a 70-year-old Indonesian-born man with comorbidities (hypertension, diabetes, COPD), underwent elective right hemicolectomy on 13 March 2017 for a suspicious ileo-caecal lesion. Biopsies were benign, CT imagi…

colorectal surgerygeneral surgerydiagnosticcommunicationmethylnatrexone
NThospital2018-09-21

Inquest into the death of David Fensom

67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …

David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings a…

general surgeryemergency medicinediagnosticcommunicationfentanyl
NThospital2018-06-19

Inquest into the death of Naomi Smith

26y · Female·Pulmonary embolism as a consequence of dislodged deep vein thrombosis

Naomi Smith, aged 26, died from pulmonary embolism caused by dislodged deep vein thrombosis while in ICU at Royal Darwin Hospital. She had complex mental health needs (BPD, PTSD, depression) and morbid obesity. The criti…

psychiatryintensive caresystemdelay

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