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VIChome2026-01-13

Finding into death of Filippo Pignataro

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…

general practiceemergency medicineamoxicillin
NThospital2026-01-09

Inquest into the death of C Guyula

49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …

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…

anaesthesiasurgeryproceduralmedicationfentanyl
VIChospital2024-12-02

Finding into death of Baby Patel

0y · Unknown·unascertained

A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…

neonatologypaediatricsdiagnosticcommunicationcefotaxime
TAScommunity2024-01-30

Coroner's Finding: Ryan, Robert John

35y · Male·Multiple organ failure - cause undetermined

Robert John Ryan, aged 35, a farm worker at Malahide, suffered a sudden severe medical collapse on 7 January 2015, presenting with vomiting, sweating, confusion, hypothermia and incontinence. Diagnosed as chemical poison…

general practiceemergency medicineparoxetine
TAScommunity2024-01-30

Coroner's Finding: Ryan, Robert John

35y · Male·Multiple organ failure—cause not determined to requisite standard

Robert John Ryan, a 35-year-old senior stockman, collapsed suddenly on 7 January 2015 at a farm gate near his workplace at Malahide in Tasmania, while driving his work utility during a normal workday. He presented with s…

toxicologyintensive carediagnosticdelayparoxetine
VIChospital2023-10-06

Finding into death of G A

86y · Female·Bradycardic arrest secondary to relative hypoperfusion while undergoing surgery …

An 86-year-old woman underwent elective surgery to excise a probable squamous cell carcinoma from her left hand with split-thickness skin grafting under local anaesthesia with intravenous sedation. She suffered an unexpe…

dermatologyplastic and reconstructive surgerymedicationpropofol
VIChospital2023-08-25

Finding into death of Mr P

26y · Male·Brain death post mixed drug toxicity including MDMA and cocaine

Mr P, a 26-year-old man, died from brain death following mixed drug toxicity from MDMA and cocaine consumed at a music festival. He presented with seizures, hyperthermia (42.2°C), and rigidity at the festival medical ten…

emergency medicineintensive careMDMA
VIChospital2023-03-20

Finding into death of Khaled El Rafihi

20y · Male·Head injury

Khaled El Rafihi, a 20-year-old apprentice electrician, died from head injuries sustained during a 'ute surfing' incident. He was sitting on the rear boot lid of a moving utility vehicle when he fell onto the road and st…

neurosurgeryintensive caremorphine
NSW2022-11-22

Inquest into the death of Kai McEwan

25y · Male·Ruptured berry aneurysm and sequelae resulting in catastrophic subarachnoid and …

A 25-year-old Aboriginal man on remand in custody collapsed during a shower and was found to have suffered a catastrophic ruptured berry aneurysm causing massive subarachnoid and intracerebral haemorrhage with brain deat…

neurosurgeryintensive careaspirin
TAScommunity2022-07-29

Coroner's Finding: Chamberlain, Pamela Jacqueline

55y · Female·asphyxia due to choking on food (steak)

A 55-year-old woman with multiple comorbidities including morbid obesity, schizophrenia, depression, and substance use disorder died from asphyxia caused by choking on food while at a friend's home in supported accommoda…

emergency medicinepsychiatrysystemcommunicationdiazepam
VIC2022-03-21

Finding into death of Nilofer Nezami

38y · Female·Unascertained

Nilofer Nezami, a 38-year-old Victorian resident, died on 7 January 2019 following cosmetic surgery in Iran. She underwent multiple procedures including eye, breast, arm and abdominal surgery. Post-operatively, she devel…

plastic and reconstructive surgeryanaesthesiasystemproceduralmorphine
NSWhospital2021-11-19

Inquest into the death of Emiliana OBUSAN

1y · Female·unrecognised oesophageal intubation

A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of pe…

anaesthesiaorthopaedic surgerydiagnosticcommunicationfentanyl
NSWhospital2021-11-09

Inquest into the death of Caitlin CRUZ

3y · Female·complications of Influenza B viral infection

Three-year-old Caitlin Cruz presented to a medical centre unwell and collapsed, requiring resuscitation. She was transferred by ambulance to Children's Hospital at Westmead but critical information about her collapse and…

emergency medicinepaediatricscommunicationdiagnosticmidazolam
VIChospital2020-10-13

Finding into death of BABY C

0y · Male·Myocarditis

Baby C, a 5-month-old infant, died from myocarditis (viral heart inflammation) after presenting to Sunshine Hospital Emergency Department with fever, breathing difficulty, and cyanosis. He waited 1 hour 52 minutes before…

emergency medicinepaediatricsdiagnosticdelayparacetamol
WAmental health2020-08-06

Inquest into the Death of Stephen Michael KELL

35y · Male·acute vomit aspiration in a man with acute large intestine obstruction (severe m…

Stephen Michael Kell, a 35-year-old man with treatment-resistant schizophrenia, died at Graylands Hospital from acute vomit aspiration in the setting of acute large bowel obstruction and clozapine-induced gastrointestina…

psychiatrygastroenterologysystemdelayclozapine
VIChome2020-08-05

Finding into death of Maxwell Rowllings

69y · Male·Complications of Downs syndrome and dementia (palliated)

Maxwell Rowllings was a 69-year-old man with Down syndrome and dementia who died in supported group accommodation. He had complex medical needs including intellectual disability, Alzheimer's disease, epilepsy, severe dys…

general practiceemergency medicineatropine
VIChospital2020

Finding into death of Jayden Kyle Morgan

21y · Male·Traumatic brain injury sustained in a motor vehicle incident (pedestrian)

Jayden Kyle Morgan, 21, died from traumatic brain injury after being struck by a car on Pearcedale Road, Cranbourne South, Victoria. He was walking along the road at 10.57pm after leaving a birthday party, having consume…

emergency medicinetrauma surgeryalcohol
VICaged care2019-07-31

Finding into death of Hong Tay

63y · Male·Sepsis in a man with complicated peripheral vascular disease

Hong Tay, a 63-year-old man with extensive peripheral vascular disease, diabetes, and prior amputations, died from sepsis in an aged care facility following a cervical spine fracture sustained in a fall. After conservati…

geriatric medicinepalliative carecommunicationsystemfentanyl
VIChospital2018-11-19

Finding into death of Robert Humphreys

71y · Male·Aspiration in setting of paralytic ileus in patient in convalescent phase of abd…

A 71-year-old man died from aspiration complicating prolonged paralytic ileus on postoperative day 9 following open abdominal aortic aneurysm repair. Despite clinical signs of persistent ileus (vomiting, abdominal disten…

vascular surgeryintensive carediagnosticdelayatropine
VIChospital2017-05-24

Finding into death of Stanley Brian Taylor

79y · Male·acute bronchitis on a background of cardiomegaly with coronary artery disease

Stanley Taylor, a 79-year-old man serving life imprisonment, died from acute bronchitis on a background of cardiomegaly with coronary artery disease. He presented to St Vincent's Hospital with chest pain and shortness of…

emergency medicinecardiologyatropine

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