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VIChome2026-03-04

Finding into death of Marko Kelentric

73y · Male·Effects of fire

A 73-year-old man died in a residential fire in rural Victoria. He was found unresponsive in his bedroom and declared deceased after fire rescue and paramedic resuscitation attempts. Autopsy confirmed death from smoke in…

systemamitriptyline
VIChome2025-09-17

Finding into death of Robert John Robinson

74y · Male·Pulmonary thromboembolism in the setting of deep leg vein thrombosis

A 74-year-old man died from pulmonary thromboembolism with deep vein thrombosis 10 days after elective umbilical hernia repair. He received appropriate VTE prophylaxis (mechanical and pharmacological) intraoperatively an…

surgeryanaesthesiacommunicationenoxaparin
VIChome2025-08-18

Finding into death of JNY

68y · Male·Unascertained

JNY, a 68-year-old man, died from unascertained causes between 1-4 September 2020. His wife, RBT, administered temazepam-laced biscuits causing unconsciousness, then wrapped and placed him in a non-operational freezer. R…

systemdelaytemazepam
QLDhospital2024-12-16

Inquest into the death of Shane Anthony May

61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…

Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory…

emergency medicinerespiratory medicineamlodipine
VIC2024-12-13

Finding into death of Michael Garry Suckling

41y · Male·Cardiomegaly in a man with WHO Class III obesity

Michael Suckling, a 41-year-old Aboriginal man, died in prison from cardiomegaly secondary to morbid obesity (BMI 54.5). He gained approximately 117kg during his 3-year incarceration, with rapid initial weight gain from …

general practicepsychiatrysystemcommunicationmethadone
VICcommunity2024-12-09

Finding into death of Forrest Caves Beach Accident

Unknown·Drowning (Reema Sondhi, Jagjeet Singh Anand, Kirti Bedi); Complications followin…

Four members of a family group from India drowned at Forrest Caves Beach, Phillip Island on 24-25 January 2024. All four deceased had limited or no swimming ability and no experience with Australian ocean conditions. The…

amlodipine
QLDhospital2024-10-18

Findings into the death of John Ainsworth

68y · Male·Cerebrovascular disease

John Raymond Ainsworth, a 68-year-old prisoner, died of cerebrovascular disease following a severe stroke on 25 November 2020. He had poorly controlled Type II diabetes, hypertension, and high cholesterol. Prior to his a…

neurologyemergency medicinedelaymetformin
WAmental health2024-07-19

Inquest into the Death of Phillip Benjamin VELTMAN

49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…

Phillip Veltman, 49, died of unascertained cause (likely cardiac arrhythmia with terminal aspiration) while an involuntary psychiatric patient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on…

psychiatryemergency medicinecommunicationsystemketamine
NSW2024-06-20

Inquest into the death of Michael Baker

44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…

Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…

general practicepsychiatrydiagnosticcommunicationmethadone
NT2024-05-30

Inquest into the death of Douglass Maggie

46y · Male·Complications arising from hyperthermia, with alcohol intoxication and underlyin…

A 46-year-old man with epilepsy, hypertension, and COPD died after prolonged exposure to heat in a locked vehicle on a hot day in Darwin. He had been drinking heavily and was left sleeping in the car while companions vis…

emergency medicineparamedicinesystemdelayalcohol
WAhospital2024-04-08

Inquest into the Death of Child SK (Name Subject to Suppression Order)

13y · Female·complications of a head injury sustained when she deliberately stepped in front …

A 13-year-old with emerging emotionally unstable personality disorder (EUPD) died by suicide after deliberately stepping in front of a car on 21 July 2020, two days after a positive appointment with mental health clinici…

psychiatryemergency medicinesystemdelaysertraline
VIChospital2023-11-02

Finding into death of Renato Ettore Poletti

72y · Male·Upper cervical spine injury sustained in a fall from a ladder

A 72-year-old man suffered a fall from a 3-metre ladder during home garden maintenance, sustaining a severe upper cervical spine injury (C2 fracture with high spinal cord haemorrhage) that was deemed non-survivable. He d…

trauma surgeryneurosurgerymidazolam
WAhome2023-06-28

Inquest into the Death of Nicholas Arthur CRIPPS

47y · Male·combined acute effects of multiple drugs in obese man with enlarged heart and ar…

Nicholas Cripps, a 47-year-old man with treatment-resistant schizophrenia, substance use disorder, and antisocial personality disorder, died from combined acute effects of multiple drugs (methylamphetamine, quetiapine, p…

psychiatrygeneral practicesystemmethamphetamine
QLDcommunity2023-04-28

A- Non-inquest findings

68y · Male·Multiple injuries sustained in a crocodile attack

A 68-year-old experienced fisherman was fatally attacked by a large saltwater crocodile (4.86m) while fishing alone in a small fibreglass dinghy in Gayundah Creek, Hinchinbrook Channel, Queensland in February 2021. Despi…

amlodipine
TAShome2023-04-20

Coroner's Finding: Young, Luke Trevor

42y · Male·mixed prescription drug toxicity (sertraline, amlodipine, lamotrigine, quetiapin…

Luke Trevor Young, 42, died from mixed prescription drug toxicity (sertraline, amlodipine, lamotrigine, quetiapine) in a suicide by overdose. He had severe, longstanding bipolar II disorder with chronic suicidality, comp…

psychiatrygeneral practicesystemdelaysertraline
NSW2023-03-14

Inquest into the death of James Brown

70y · Male·Hemopericardium due to ruptured aortic dissection contributed to by hypertension

Mr James Brown, a 70-year-old prisoner with a long-standing history of hypertension and atrial fibrillation, died from hemopericardium due to ruptured aortic dissection. He collapsed with chest pain while at work in the …

emergency medicinevascular surgeryprazosin
VICaged care2023-02-23

Finding into death of H D

87y · Female·Complications following a medication administration error in a woman with multip…

An 87-year-old woman died from complications of a medication administration error at an aged care facility. During transition from paper-based to electronic medication charts in December 2020, a pharmacy data entry error…

geriatric medicinegeneral practicemedicationsystemrisedronate
TAShospital2023-02-20

Coroner's Finding: de-identified RI

68y · Male·community-acquired pneumonia in a setting of advanced centriacinar emphysema, al…

A 68-year-old man died of community-acquired pneumonia complicated by asplenia (absent splenic function), chronic liver disease from alcohol misuse, and severe malnutrition. He presented with syncopal episodes, cachexia,…

general medicinegeneral practicediagnosticcommunicationparacetamol
QLD2023-01-25

Civic, Mirko

70y · Male·Coronary atherosclerosis

Mirko Civic, a 70-year-old prisoner with a significant cardiac history including prior myocardial infarction, hypertension, and ischaemic heart disease, died of coronary atherosclerosis in September 2018. Critical clinic…

cardiologygeneral practicediagnosticmedicationaspirin
VIChospital2022-10-05

Finding into death of Douglas Earnest Stott

72y · Male·Diffuse large B cell lymphoma

Douglas Stott, a 72-year-old prisoner with diffuse large B cell lymphoma, died of natural causes in hospital on 7 January 2021. He had been receiving telehealth oncology consultations while incarcerated but refused in-pe…

oncologyhaematologysystemdelayibrutinib

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