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VIChome2026-04-14

Finding into death of James Thomas Reilly

86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall

James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…

emergency medicinegeneral medicinediagnosticmedicationenoxaparin
QLD2026-01-30

Inquest into the death of Garry Reginald Dubois

74y · Male·Incised wounds to limbs; other significant conditions being ischaemic heart dise…

Garry Reginald Dubois, a 74-year-old serving a life sentence for serious offences, died in custody from self-inflicted incised wounds to his limbs. He was on dual antiplatelet therapy for ischaemic heart disease, which c…

cardiologygeneral practiceclopidogrel
NSWhospital2025-12-08

Inquest into the death of Katrina McGrady

43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm

Trina McGrady, a 43-year-old Goomeroi woman, died from subarachnoid haemorrhage due to a ruptured berry aneurysm on 15 September 2020. She had been admitted to John Hunter Hospital following incidental discovery of two l…

neurosurgeryradiologycommunicationdiagnosticaspirin
VIChospital2025-10-10

Finding into death of Jeffrey George Nirens

70y · Male·intracranial haemorrhage secondary to haemorrhagic transformation of ischaemic s…

A 70-year-old man with chronic small vessel cerebral ischaemia died from intracranial haemorrhage following haemorrhagic transformation of an ischaemic stroke while in prison custody. He presented with acute stroke sympt…

neurologyemergency medicinemedicationsystemenoxaparin
NSWcustodial setting (correctional facility) with death at hospital2025-07-23

Inquest into the death of James Cunneen

60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…

James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…

general practiceinfectious diseasesdiagnosticmedicationpantoprazole
VIChome2025-02-14

Finding into death of Martin Barlow

67y · Male·Head injuries sustained in falls

Martin Barlow, 67, died from head injuries sustained in two falls on 5 August 2022 while intoxicated (BAC 0.17 g/100mL). He suffered subarachnoid haemorrhage and subdural haemorrhage. After Ms Burrell called emergency se…

emergency medicineparamedicinedelaysystemalcohol
TAShospital2024-09-30

Coroner's Finding: Newell, Warren James

71y · Male·raised intracranial pressure caused by left frontal-temporal-parietal subdural h…

Warren James Newell, a 71-year-old man with oesophageal cancer, presented with acute coronary syndrome on 29 September 2022 and was appropriately diagnosed and treated with anticoagulation and dual antiplatelet therapy. …

cardiologyemergency medicinemedicationsystemenoxaparin
ACTaged care2023-04-06

Inquest into the Death of Ruth McKay

90y · Female·acute bronchopneumonia caused by Staphylococcus aureus

Ruth McKay, 90, died of acute bronchopneumonia after accessing the external courtyard of the Memory Support Unit (MSU) at an aged care facility undetected in the early morning of 17 January 2015. She was found under a st…

geriatric medicineemergency medicinesystemcommunicationamitriptyline
NSWprison2023-03-01

Inquest into the death of William Haines

37y · Male·Pulmonary thromboembolus due to left leg deep vein thrombosis

A 37-year-old Aboriginal man died of pulmonary thromboembolism due to deep vein thrombosis while incarcerated. He presented to hospital on his birthday with lethargy, shortness of breath, and tachycardia. Initial assessm…

emergency medicinecardiologydiagnosticsystemenoxaparin
WAprison2022-12-13

Inquest into the Death of William Frederick ANDERSON

53y · Male·intracerebral haemorrhage

William Anderson, an Aboriginal man aged 53, suffered a catastrophic intracerebral haemorrhage while imprisoned and died despite timely emergency response. Multiple delays occurred: 25 minutes before the cell was opened,…

emergency medicineneurologydelaysystemaspirin
VIChome2022-08-15

Finding into death of John Disley

80y · Male·Multiple injuries post fall from a roof

An 80-year-old man died from multiple injuries sustained in a fall from a roof while cleaning gutters at home. He fell approximately 2 metres from a ladder, sustaining rib, pelvis, and spine fractures, plus vertebral art…

trauma surgerycardiologyaspirin
VIChospital2022-05-06

Finding into death of Trevor Anthony Peterson

57y · Male·Sepsis from ischemic bowel due to superior mesenteric artery thrombus

Trevor Peterson, a 57-year-old with chronic gut ischemia, underwent mesenteric artery stenting in February 2020. Discharge instructions emphasising dual antiplatelet therapy (DAPT) were not clearly communicated to the va…

vascular surgeryradiologycommunicationsystemaspirin
NSWhospital2022-03-25

Inquest into the death of Anthony Barrett

54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…

Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…

orthopaedic surgeryvascular surgerycommunicationdiagnosticclopidogrel
TAShome2021-12-20

Coroner's Finding: Donohue, Tracey Lee

44y · Female·Ischemic heart disease due to complete blockage of left anterior descending coro…

A 44-year-old woman presented with acute chest pain and troponin elevation. Coronary angiography revealed only a 30% non-obstructive lesion in the left anterior descending artery. She was discharged on aspirin alone with…

cardiologyemergency medicinediagnosticmedicationaspirin
QLDhospital2021-02-24

Fullerton, Robert Martin

59y · Male·Disseminated carcinoma on a background of emphysema

Robert Fullerton, a 59-year-old Aboriginal man from Palm Island, died from disseminated carcinoma while remanded in custody at Townsville Correctional Centre. He presented with abdominal pain on 5 December 2018, was diag…

oncologycardiologyprazosin
QLDaged care2020-12-18

Murphy, Maxwell

89y · Male·multi-organ failure with pneumonia due to ingestion of a corrosive liquid (quate…

An 89-year-old man with severe dementia died from multi-organ failure following ingestion of concentrated Bacban (quaternary ammonium compound) left in his bathroom at an aged care facility. The cleaning staff member ina…

emergency medicineintensive carediagnosticcommunicationbacban
QLDprison2020-12-17

Hobbs, Richard William

48y · Male·Coronary atherosclerosis with acute cardiac event

Richard William Hobbs, aged 48, died from cardiac arrest in custody at Brisbane Correctional Centre on 21 November 2017. He had significant comorbidities including coronary artery disease (recent stent insertion), diabet…

emergency medicinecardiologydiagnosticcommunicationaspirin
SA2020-05-08

Coroner's Finding: CANHAM Craig Nicholas

63y · Male·cardiac arrhythmia complicating recent posterior myocardial infarct with underly…

Craig Nicholas Canham, aged 63, died in custody at Yatala Labour Prison from cardiac arrhythmia complicating a recent posterior myocardial infarction with underlying hypertrophic cardiomyopathy. He had suffered a myocard…

cardiologygeneral practicetenecteplase
QLDhospital2019-09-03

Mr DAC - Non-inquest findings

51y · Male·Sepsis due to or as a consequence of right lower limb necrotising fasciitis due …

A 51-year-old man with metastatic renal cell carcinoma died from sepsis following necrotising fasciitis of the lower limb, which developed after a pseudo-aneurysm complication from coronary angiography. Key clinical less…

cardiologyvascular surgerydiagnosticproceduralpazopanib
VICaged care2019-05-30

Finding into death of S B

87y · Male·Complications of head injuries in setting of dementia

An 87-year-old man with vascular dementia died from complications of head injuries sustained in assaults by a fellow nursing home resident. The deceased had a documented tendency to wander and enter other residents' room…

geriatric medicineforensic medicinesystemcommunicationclopidogrel

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