755 results
52y · Male·perforation of a hollow viscus complicating oesophageal cancer in a man with cer…
Adam Barry, a 52-year-old man with cerebral palsy, dysphagia, and epilepsy, was diagnosed with metastatic oesophageal cancer in February 2024 after presenting to hospital with vomiting. Living in Specialist Disability Ac…
74y · Male·Pulmonary thromboembolism due to right deep vein thrombosis
Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond t…
92y · Male·respiratory failure secondary to bilateral pleural effusions on a background of …
Hans Biermann, aged 92, died on 1 March 2023 following respiratory failure secondary to bilateral pleural effusions and rib fractures sustained in a fall at Regis Playford aged care facility on 23 February 2023. Mr Bierm…
77y · Female·Ischaemic heart disease
Gayle Patricia Carley, 77, collapsed unwitnessed at home with acute ischaemic heart disease on 19 October 2023. Ambulance paramedics arrived and initiated emergency treatment, but a MICA paramedic inadvertently administe…
47y · Male·Multiple blunt force injuries to the neck, chest and lower limbs sustained in a …
A 47-year-old male passenger died from multiple blunt force injuries (bilateral pneumothoraces, pulmonary contusions, ruptured spleen, pelvic fractures, cervical spine fracture with spinal cord haemorrhage) from a high-s…
14y · Female·unascertained natural causes – possibly encephalitis leading to seizure or sudde…
SMS, a 14-year-old previously healthy girl, collapsed unexpectedly at home on 10 October 2021 and was found unresponsive and not breathing. Immediate resuscitation was commenced by family members and emergency services, …
Male·toxicity caused by a combination of methylamphetamine and morphine
Felipe Esteban Alvarez died on 30 March 2021 from toxicity caused by methylamphetamine and morphine (heroin) ingestion at his unit in Taylor, ACT. He collapsed after self-injecting heroin in the presence of others, inclu…
Male·stage 4 lung cancer with pleural metastases
Kenneth Plumstead died of stage 4 lung cancer with pleural metastases at Launceston General Hospital on 18 October 2014, receiving appropriate palliative care including morphine pain relief. Eleven years later, his widow…
23y · Female·Methylamphetamine toxicity
Patience Kuzmins, 23, died in custody at Silverwater Women's Correctional Centre on 10 November 2022 from methylamphetamine toxicity caused by an internally concealed package. The coroner found that Patience was not stri…
40y · Male·ligature compression of the neck (hanging)
Mason Shahzad, a 40-year-old sentenced prisoner serving 30 years for serious family violence offences, died by ligature hanging in his cell at Acacia Prison on 11 November 2024. He had a history of depression, PTSD, and …
40y · Male·Unascertained
Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…
32y · Female·Unable to be determined
A 32-year-old woman with obesity was prescribed Ozempic 1mg weekly in August 2024 (above the recommended starting dose) for weight management. She developed prolonged gastrointestinal symptoms and took loperamide for dia…
11y · Male·Effects of fire
An 11-year-old Aboriginal boy died in a house fire on 19 December 2022, along with the homeowner who attempted rescue. The fire started in the homeowner's bedroom, most likely from a carelessly discarded cigarette, and s…
1y · Female·Rapidly developing Streptococcus pneumoniae infection leading to invasive pneumo…
Arianna Maragol, a 16-month-old girl, died from rapidly developing Streptococcus pneumoniae infection leading to invasive pneumococcal disease while in childcare on 24 August 2018. Key clinical lessons emerged: (1) Pneum…
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…
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…
53y · Male·Sepsis secondary to aspiration pneumonia
Giovanni John Miceli, a 53-year-old man with cerebral palsy and intellectual disability living in specialist disability accommodation, died from sepsis secondary to aspiration pneumonia. He had a known history of recurre…
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…
1y · Male·Complications of acute lymphoblastic leukaemia
Sandipan Dhar, 21 months old, died from undiagnosed acute lymphoblastic leukaemia (ALL) complicated by sepsis and pneumonia on 24 March 2024. After three weeks of intermittent fever, he attended his GP three times and wa…
66y · Male·metastatic adenocarcinoma (palliated) from an unidentified primary tumour
Bradley John Murdoch, a 66-year-old prisoner serving a life sentence for murder, died in the palliative care unit of Alice Springs Hospital from metastatic adenocarcinoma on 15 July 2025. He had presented to the correcti…
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