216 results
78y · Male·Complications of acute renal impairment in the setting of pelvic and lumbar frac…
Garry Ledger, 78-year-old South Australian visitor, died three weeks after falling on a Melbourne tram on 28 August 2025. While boarding tram route 16, he fell during tram acceleration while using his Myki card and befor…
63y · Female·1a: Aspiration pneumonia in a woman with acquired brain injury, 1b: Cerebrovascu…
Susan Czudar, 63, died of aspiration pneumonia complicated by acquired brain injury from a 2017 subarachnoid haemorrhage and multiple strokes. Residing in NDIS-funded specialist disability accommodation, she was admitted…
32y · Female·cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage
Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. mis…
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, …
70y · Male·metastatic gastric adenocarcinoma
A 70-year-old man with prior bladder cancer was undergoing routine CT surveillance. Stomach cancer signs were clearly visible on February 2017 and February 2018 CT scans but failed to be detected by consulting radiologis…
<1y · Female·Transposition of the Great Arteries
Thea Flaskett was born at Redcliffe Hospital on 11 September 2023 with undiagnosed transposition of the great arteries (TGA), a critical congenital heart defect requiring urgent diagnosis and specialist intervention. She…
87y · Female·Oesophageal perforation following an elective oesophageal dilatation, secondary …
87-year-old Helen Mahlis died from oesophageal perforation following an elective balloon dilation procedure at Epworth Richmond for treatment of achalasia. The coroner identified two contributing factors: use of a 35mm b…
50y · Male·unascertained
Simon Gaskill, aged 50, was found deceased in sand dunes at Ocean Grove Beach in April 2022 after sleeping rough for months. He had been discharged from hospital in December 2021 following treatment for severe alcohol wi…
70y · Male·Metastatic melanoma with ischaemic heart disease as a contributing condition
Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…
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…
22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…
Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…
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…
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…
35y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to vertebro…
A 35-year-old woman presented to a rural hospital with a three-day history of collapses, slurred speech, vomiting, and abnormal eye movements. A non-contrast CT head scan was normal, and she was discharged with a diagnos…
50y · Male·Metastatic carcinoma of unknown primary
Joel Charles Buckley, a 50-year-old man with intellectual disability residing in specialist disability accommodation, died from metastatic carcinoma of unknown primary. He presented with back and shoulder pain in March 2…
43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm
Trina McGrady, a 43-year-old Goomeroi woman, died from subarachnoid haemorrhage due to a ruptured berry aneurysm on 15 September 2020. She had been admitted to John Hunter Hospital following incidental discovery of two l…
90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …
A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …
57y · Female·Multi-organ failure due to drug-induced liver injury caused by sodium valproate …
Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nau…
<1y · Male·Non-accidental infliction of significant force to the head/face and gum region, …
Jacob, a premature infant born at 29 weeks, was discharged from neonatal care at 11 weeks old and presented to hospital three days later with a subarachnoid haemorrhage and periorbital bruising. Despite being assessed as…
62y · Male·Complications of metastatic malignancy (likely lung primary)
Colin James Whaley, aged 62, died from complications of metastatic lung cancer while in custody at Junee Correctional Centre. He was a heavy smoker admitted to prison in June 2023. Significant weight loss (40kg) during i…
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