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…
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…
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…
62y · Male·Aspiration pneumonia complicating epilepsy in the setting of Down syndrome
Richard Watson, a 62-year-old man with Down syndrome, epilepsy, dementia and C1 partial quadriplegia, died from aspiration pneumonia at Austin Hospital. He had recurrent admissions over six months for pneumonia, asthma a…
66y · Male·Complications of multiple sclerosis and left tongue squamous cell carcinoma
George Scott Boyens, a 66-year-old with multiple sclerosis and newly diagnosed left tongue squamous cell carcinoma, died from complications of these conditions following a brief palliative care admission. He was admitted…
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…
71y · Male·Complications of rib fractures, liver laceration and pneumothorax sustained in a…
Anthony Joseph Moore, 71, died from complications of rib fractures, liver laceration and pneumothorax sustained in a fall at Bundoora Park on 15 August 2025. While being assisted by a disability support worker near a ben…
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, …
49y · Female·Aspiration pneumonia in the setting of cerebral palsy and epilepsy
Louise Hayes, a 49-year-old woman with cerebral palsy, epilepsy, and dysphagia, died from aspiration pneumonia at Kilmore & District Hospital. She had experienced deteriorating health in 2020 with increased seizures and …
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
A 62-year-old man died from intraoperative haemorrhage during surgery for a renal tumour initially diagnosed as benign anastomosing haemangioma on biopsy but found at autopsy to be metastatic clear cell renal cell carcin…
45y · Female·Complications of sepsis secondary to sacral pressure wound in a woman with genet…
Kristy Ann Mitchener, a 45-year-old woman with severe intellectual disability, genetic developmental and epileptic encephalopathy, and oesophageal dysmotility, died from sepsis secondary to a sacral pressure ulcer despit…
58y · Male·Pulmonary thromboembolism complicating right calf deep venous thrombosis
Michael Burns, 58, presented to hospital with exertional chest pain and shortness of breath. He was diagnosed with stable angina and discharged home on cardiac medications. He returned the next day with dizziness attribu…
58y · Male·Sepsis of unknown origin on a background of multiple co-morbidities
Michael Francis Gribble, a 58-year-old man with complex medical comorbidities including alcoholic cardiomyopathy, schizophrenia, and acquired brain injury, died from sepsis of unknown origin at Rosebud Hospital. He was f…
52y · Male·Pulmonary thromboembolism
A 52-year-old man with autism, intellectual disability, and multiple comorbidities died from pulmonary thromboembolism at home. He developed respiratory symptoms on 24 March, was managed in primary care with telehealth a…
57y · Male·Lung abscess and bronchopneumonia
Terrence Michael O'Sullivan, a 57-year-old man with intellectual disability, blindness, deafness and epilepsy, died from lung abscess and bronchopneumonia caused by Klebsiella oxytoca. He presented with a pressure wound …
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