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VICcommunity2026-07-23

Finding into death of Danielle Meredith Noonan

51y · Female·Chest sepsis in the setting of recurrent aspiration pneumonia, cerebral palsy, L…

Danielle Noonan, aged 51, died from chest sepsis secondary to recurrent aspiration pneumonia. She had severe disability including cerebral palsy, Lennox-Gastaut syndrome, spastic quadriplegia, and intellectual disability…

general medicineneurologymedicationcarbamazepine
VIChome2026-07-23

Finding into death of Adam Donald Baker

50y · Male·Cerebral haemorrhage (cause unknown)

Adam Donald Baker, a 50-year-old man with Christianson Syndrome (a genetic disorder causing intellectual disability and seizures), died from cerebral haemorrhage of unknown cause while residing in supported disability ac…

general practiceneurologylevetiracetam
VIChome2026-02-18

Finding into death of Glenn Charles Cook

66y · Male·Cardiac hypertrophy and coronary artery disease secondary to obesity (WHO Class …

Glenn Cook, a 66-year-old man with moderate intellectual disability living in Specialist Disability Accommodation, died from cardiac hypertrophy and coronary artery disease secondary to obesity and hypercholesterolaemia.…

general practicepsychiatryquetiapine
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
VIChospital2025-10-17

Finding into death of Raymond Charles Levy

75y · Male·Aspiration pneumonia in the setting of epilepsy and cerebral palsy

Raymond Charles Levy, a 75-year-old man with cerebral palsy and epilepsy living in supported disability accommodation, died from aspiration pneumonia. He presented to hospital with fatigue, fever and cough on 18 October …

general medicineemergency medicineceftriaxone
VIC2025-10-08

Finding into death of Richard Paul Atkins

65y · Male·Ischaemic heart disease in a man with epilepsy

Richard Paul Atkins, a 65-year-old man with intellectual disability and epilepsy living in specialist disability accommodation, died from ischaemic heart disease. Post-mortem examination revealed moderate to severe tripl…

cardiologyneurologycarbamazepine
VICmental health2025-07-14

Finding into death of Maxwell Bernard Howard

84y · Male·Bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart di…

Maxwell Howard, 84, died from bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart disease while admitted to a mental health acute unit under a Temporary Treatment Order. He had multiple comorbid…

psychiatryemergency medicinecarbamazepine
VIChome2024-10-09

Finding into death of D M

43y · Female·Combined drug toxicity (tapentadol, sertraline, gabapentin, periciazine, carbama…

A 43-year-old woman with complex psychiatric history including schizoaffective disorder, borderline personality disorder, and chronic suicidality died from combined drug toxicity involving eight medications (tapentadol, …

psychiatrygeneral practicecommunicationsystemtapentadol
NSW2024-03-06

Inquest into the death of WM

59y · Male·Hanging

A 59-year-old man serving a life sentence died by hanging in his segregation cell at Lithgow Correctional Centre on 2-3 April 2020. He had a history of depression, anxiety, and a prior serious self-harm attempt in 2010 r…

psychiatryforensic medicinesystemmirtazapine
VICcommunity2024-01-15

Finding into death of Michael John O'connell

57y · Male·Pneumonia

Michael John O'Connell, a 57-year-old man with Down's syndrome and Alzheimer's disease-related cognitive decline, died from pneumonia while resident in specialist disability accommodation. On 26 April 2023, he exhibited …

general practicedisability medicinedelaymirtazapine
VICcommunity2023

Finding into death of Ms KSQ

39y · Female·Plastic bag asphyxia

Ms KSQ, aged 39, died by plastic bag asphyxia in May 2023. She had experienced alleged sexual abuse and coercive control from her partner over 12 years. In September 2022, when she attempted to change locks at the family…

diagnosticsystemclobazam
VICcommunity2022-11-23

Finding into death of Carl Robert Adler

46y · Male·Cold environmental exposure in a man with cardiomegaly

Carl Robert Adler, a 46-year-old man with treatment-resistant schizophrenia, intellectual disability, and autism, died from cold environmental exposure complicated by pre-existing cardiomegaly after leaving a community c…

psychiatrydiagnosticsystemclozapine
VICcommunity2022-11-22

Finding into death of Vlado Tomislav Micetic

44y · Male·gunshot wound to the abdomen

Vlado Micetic, 44, was fatally shot by Leading Senior Constable Timothy Baker during a traffic interception for stolen number plates in Windsor, Victoria, on 25 August 2013. Baker claimed Micetic produced a knife during …

emergency medicinepsychiatrysystemdelaycarbamazepine
VIChospital2022-11-21

Finding into death of Glenda Elaine Shapcott

65y · Female·Pneumonia and right hip haematoma following a fall in a woman with multiple medi…

Glenda Shapcott, a 65-year-old woman with intellectual disability and multiple comorbidities, died from pneumonia and hip haematoma following a fall. She lived in supported disability accommodation and was under a pallia…

general practiceemergency medicinecarbamazepine
NSW2022-10-21

Inquest into the death of Alex Raichman

11y · Male·Multiple injuries sustained when struck by train

Alex Raichman, 11, died when struck by a train after absconding from respite care at Civic Disability Services. Alex had autism, intellectual disability, and seizure disorder with documented absconding risk. Civic knew w…

paediatricspsychiatrysystemproceduralaripiprazole
VIChome2022-09-27

Finding into death of Colleen Mary Chapman

59y · Female·Myocardial infarction secondary to ischaemic heart disease

Colleen Mary Chapman, a 59-year-old woman with intellectual disability living in a community residential unit, died of myocardial infarction secondary to ischaemic heart disease, with WHO Class IV obesity as a contributi…

cardiologyemergency medicinesystemcommunicationcarbamazepine
VIChospital2022-08-10

Finding into death of Dimitrios Alexandrou

52y · Male·Gastric adenocarcinoma

Dimitrios Alexandrou, a 52-year-old man with severe cerebral palsy, intellectual disability, and drug-resistant epilepsy, died from gastric adenocarcinoma. He presented in July 2021 with weight loss and reduced appetite;…

oncologypalliative careepilim ec
VIChospital2022-05-04

Finding into death of Marlene Sako

25y · Female·self-immolation

Marlene Sako, a 25-year-old woman struggling with alcohol dependence following a traumatic marriage breakdown, presented to Northern Hospital on 29 November 2015 with threats of self-harm and suicide attempts. Despite a …

emergency medicinepsychiatrydiagnosticcommunicationalcohol
SAhospital2021-11-23

Coroner's Finding: Barry, Margaret Joan

80y · Female·Right haemothorax due to bleeding right pleural adhesion with contributing apixa…

Margaret Joan Barry, 80, died from right haemothorax due to bleeding from a pleural adhesion while on apixaban anticoagulation therapy for atrial fibrillation. She was admitted to Royal Adelaide Hospital for psychiatric …

psychiatrycardiologyapixaban
QLD2021-09-20

Harris, John Edward

47y · Male·Hanging

John Harris, a 47-year-old life prisoner at Townsville Correctional Centre, died by hanging in his cell on 4 July 2019. He had an elevated baseline suicide risk due to a previous 2012 suicide attempt, yet was housed in a…

correctional healthpsychologyassessmentsystemcarbamazepine

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