Steven Thelander, aged 29, died from ketoacidosis due to poorly controlled Type 1 diabetes while in residential disability support care at Multicap. He had cerebral palsy with severe intellectual impairment and epilepsy …
Sharon Harris, 63, died from aspiration pneumonia complicated by seizure disorder, Down syndrome, dementia, and normal pressure hydrocephalus. She was in specialist disability accommodation in Colac. In the months before…
Joshua Tyrrell, 28, died from multiple head, facial and spinal injuries sustained in a motorbike crash on the Brooker Highway. He was riding at excessive speed and failed to maintain steering control through a bend. Toxi…
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…
A 56-year-old man with congenital microcephaly, intellectual disability, dysphagia and recurrent aspiration pneumonia died from aspiration pneumonia whilst receiving palliative care in hospital. He had multiple episodes …
Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …
Lydia Christopherson, a 39-year-old woman with cerebral palsy, intellectual disability, and epilepsy living in supported accommodation, died from a large right pleural effusion complicated by chest infection. She present…
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…
An 80-year-old woman died from injuries sustained in a motor vehicle collision after likely experiencing a seizure or similar medical episode while driving. She had a history of traumatic brain injury from 1972 and a doc…
Dominic Joshua Clifford, a 23-year-old with a complex history of mental illness including depression, anxiety, ADHD, and likely autism spectrum disorder, died by nitrogen gas inhalation in September 2024. He had multiple…
A 34-year-old woman with complex medical history including chronic pain, sleep disorder, anxiety and PTSD died from combined drug toxicity involving gabapentin, oxycodone, tramadol, diazepam, citalopram, desmethylvenlafa…
A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…
A 33-year-old Indigenous man with Type 2 diabetes, hypertension and dyslipidemia collapsed while playing football in a prison in July 2023, sustaining an out-of-hospital cardiac arrest from which he did not recover. Auto…
John Frylinck, a 70-year-old man with Alzheimer's disease and poorly controlled type 2 diabetes, disappeared on 18 January 2024 while walking at Mundaring Sculpture Park. Despite an extensive search involving 120 volunte…
A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner ident…
A 43-year-old man with long-standing opioid use disorder and polysubstance dependence died from hypoxic brain injury following cardiac arrest caused by drug poisoning. He had been prescribed large quantities of pregabali…
Michelle Darragh, a 32-year-old social worker, was fatally stabbed by her former partner Benjamin Coman on 9 October 2021. She was pregnant with their third child. The relationship involved progressive coercive control, …
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 …
Si Ro Vo, a 61-year-old male imprisoned since April 2025, died from metastatic lung cancer with brain involvement while in palliative care at the prison inpatient unit. He had an Acute Resuscitation Plan documenting comf…
Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…
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