Coronial
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SAcommunityNew2026-08-21

Coroner's Finding: Holden, Richard Arthur

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…

general practiceemergency medicinediagnosticdelaysalbutamol
VIChospital2026-07-23

Finding into death of Vicki Karon Grigg

67y · Female·Pulmonary thrombo-embolism secondary to deep venous thrombosis, with contributin…

Vicki Grigg, 67, died from pulmonary embolism three days after discharge from Goulburn Valley Health. She had been admitted with influenza A exacerbating asthma and COPD, and received standard-dose anticoagulation prophy…

respiratory medicineemergency medicinemedicationcommunicationenoxaparin
NSWhospital2026-07-13

Inquest into the death of Wen Liang Zhang

57y · Male·Metastatic lung adenocarcinoma

Wen Liang Zhang was a 57-year-old remand prisoner diagnosed with metastatic lung adenocarcinoma shortly after arrest on 26 September 2025. He declined chemotherapy and radiotherapy, choosing palliative pain management in…

oncologypalliative careoxycodone
QLD2026-07-08

Inquest into the death of Francis Lex Deemal

70y · Male·Chronic kidney disease, with atherosclerotic cardiovascular disease and type 2 d…

Francis Lex Deemal, a 70-year-old Indigenous man from Hope Vale, Cape York, died at Mareeba Hospital on 2 August 2023 from chronic kidney disease, with atherosclerotic cardiovascular disease and type 2 diabetes as contri…

correctional healthnephrologyinsulin
QLDhospital2026-07-07

Inquest into the death of Maxwell John Beever

83y · Male·Metastatic melanoma

Maxwell John Beever, aged 83, died from metastatic melanoma on 8 July 2022 while in custody at Robina Hospital. A suspicious skin lesion was documented on 26 February 2021 but not investigated until 26 June 2021, delayin…

emergency medicinegeneral medicinedelaydiagnosticoxycodone
QLDaged care2026-06-09

Non-inquest findings into the death of Mr H (3 of 3 linked pressure injury cases)

87y · Male·Multiorgan failure due to sepsis due to skin failure, underlying vascular dement…

An 87-year-old man with vascular dementia and stroke-related quadriplegia developed a sacral pressure injury in a residential aged care facility in December 2023. Despite care interventions, the wound rapidly deteriorate…

general practicepalliative carediagnosticcommunicationantibiotics
VICaged care2026-04-30

Finding into death of Sandra Susan Black

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…

general practiceemergency medicineantibiotics
VIChospital2026-04-14

Finding into death of Giovanni John Miceli

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…

infectious diseasesemergency medicineantibiotics
VIC2026-03-19

Finding into death of Judith Gail Longhurst

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…

respiratory medicinegeneral practicesertraline
SA2026-03-13

Coroner's Finding: Holding, Matthew Benjamin

44y · Male·unascertained

Matthew Benjamin Holding, aged 44, died suddenly in prison on 2 January 2023. He had schizophrenia managed with antipsychotics and severe obesity (BMI 41.6). In December 2022, he showed signs of significant deterioration…

psychiatrycorrectional healtholanzapine
VIChospital2026-03-02

Finding into death of Cameron James Stewart

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, …

general practiceemergency medicinediazepam
NSWhospital2026-02-19

Inquest into the death of Taulima Parker

75y · Male·metastatic pancreatic cancer

A 75-year-old man died from metastatic pancreatic cancer while in lawful custody. He was diagnosed in February 2025 and underwent palliative chemotherapy at Prince of Wales Hospital from March-April 2025. He developed an…

oncologypalliative caregemcitabine
VIChospital2026-02-12

Finding into death of Kristy Ann Mitchener

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…

general practiceemergency medicinesystemcommunicationantibiotics
VIChospital2026-01-29

Finding into death of William Anthony Daniel

72y · Male·Complications of a gastroduodenal perforation (palliated) in the setting of mult…

William Anthony Daniel, a 72-year-old SDA resident with intellectual impairment and multiple comorbidities, presented to Box Hill Hospital on 7 November 2024 with postural hypotension, nausea, vomiting and abdominal pain…

general surgeryemergency medicineantibiotics
VIChospital2026-01-13

Finding into death of Sushant Padhye

56y · Male·Recurrent aspiration pneumonia in a man with congenital disability and cognitive…

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 …

emergency medicinepalliative carecarbamazepine
TAShospital2025-12-09

Coroner's Finding: de-identified EM

76y · Female·sepsis as a result of myocarditis and tricuspid valve endocarditis (infective en…

A 76-year-old woman with vascular dementia and emphysema was admitted with sepsis of unknown origin, treated with antibiotics, and discharged after 12 days with improving symptoms. She re-presented 14 days later with rec…

emergency medicinecardiologydiagnosticcommunicationantibiotics
VIChospital2025-12-08

Finding into death of Graeme William Kenny

61y · Male·Right lower lobe pneumonia

Graeme William Kenny, a 61-year-old man with trisomy 21 and dementia, died from right lower lobe pneumonia on 25 December 2024 at Monash Medical Centre following palliative care. He developed upper respiratory symptoms o…

emergency medicinegeneral practicediagnosticdelayibuprofen
VIChospital2025-12-01

Finding into death of Larelle Sheridan Dean

51y · Female·Multiorgan failure in the setting of WHO Class III obesity, chronic excessive al…

A 51-year-old woman with WHO Class III obesity, chronic alcohol consumption, and anaemia died of multiorgan failure following admission with community-acquired pneumonia and respiratory failure. She presented with abdomi…

general medicineemergency medicinehydromorphone
VIChospital2025-11-18

Finding into death of David William James Hearn

57y · Male·Aspiration pneumonia in a man with cerebral palsy, intellectual disability and L…

A 57-year-old man with cerebral palsy, intellectual disability, and Lennox-Gastaut syndrome died from aspiration pneumonia following a short hospital admission. He had a history of recurrent aspiration pneumonia and was …

respiratory medicineemergency medicineantibiotics
SAhospital2025-11-14

Coroner's Finding: Menzies, Jason Douglas

33y · Male·Marburg variant of multiple sclerosis

Jason Menzies, aged 33, died in custody from Marburg variant multiple sclerosis after rapid neurological deterioration. He initially presented with urinary retention on 1 December 2022, which was appropriately investigat…

emergency medicinegeneral medicineamitriptyline
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