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VICcommunity2026-05-07

Finding into death of Elizabeth Susan Edwina Ferris

44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…

Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…

psychiatryintensive carediagnosticcommunicationheroin
VICmental health2026-04-27

Finding into death of GM

Female·Fulminant hepatic failure due to paracetamol toxicity

A 19-year-old female with anorexia nervosa, borderline personality disorder, and chronic suicidality was admitted to St Vincent’s psychiatric inpatient unit on 28 July 2023. She reported ongoing suicidal thoughts but eng…

psychiatryintensive careparacetamol
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
QLDhospital2025-10-23

Inquest into the death of Shirley Elizabeth Haggett

78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…

78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…

anaesthesiaplastic and reconstructive surgerysystemdiagnosticmidazolam
VIChome2025-10-06

Finding into death of Ivy Bella Roze Egan-Lee

4y · Female·Hypoxic ischaemic encephalopathy following immersion

A 4-year-old girl drowned in a neighbouring pool after crawling through a gap in a shared boundary fence that served as a pool safety barrier. The fence had been certified as compliant in February 2024 but deteriorated s…

systemfentanyl
QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…

emergency medicineinfectious diseasesdiagnosticdelayantacid
NSWhospital2025-08-14

Inquest into the death of Margaret Mariani

88y · Female·Complications of cholecystectomy surgery

Margaret Mariani, 88, died from complications of laparoscopic cholecystectomy for gallstone-induced pancreatitis. An iatrogenic small bowel perforation, likely caused by inadvertent suturing during closure, led to perito…

surgerygeneral surgerycommunicationdelayfentanyl
VIChospital2025-01-28

Finding into death of Dustin Buckley

17y · Male·Gunshot wound to the head

Dustin Buckley, 17, died from a gunshot wound to the head at Royal Melbourne Hospital on 27 August 2017. The incident occurred during target shooting at Cat Track when KD fired a .22 rifle that discharged, striking Dusti…

trauma surgeryemergency medicinesystemproceduralmidazolam
VIChome2025-01-08

Finding into death of Ivy McGowan

28y · Female·Cerebral x-linked adrenoleukodystrophy

Ivy McGowan, a 28-year-old NDIS participant with cerebral x-linked adrenoleukodystrophy, died at home on 5 October 2023 from natural causes. She had experienced progressive deterioration from late 2022, with increasing n…

palliative caregeneral practicefentanyl
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
VIChospital2024-11-26

Finding into death of Zarif Haidary

20y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

A 20-year-old male died from multiple injuries sustained in a head-on motor vehicle collision. He was driving a utility vehicle at 153-161 km/h in a 70 km/h zone, overtaking other vehicles on the wrong side of the road a…

trauma surgeryintensive carefentanyl
QLDmental health2024-09-17

Inquest into the death of Chloe Jane Campbell

32y · Female·Hypoxic-ischaemic encephalopathy due to hanging

Chloe Jane Campbell, aged 32, died by suicide while an involuntary inpatient with borderline personality disorder, complex PTSD, and chronic suicidal ideation. She was admitted 18-30 April 2019 after ceasing medications …

psychiatryintensive caresystemlorazepam
SA2024-09-13

Coroner's Finding: Mortess, Noel Allen

75y · Male·End stage myelodysplastic syndrome and end stage renal failure on a background o…

A 75-year-old man died in prison custody from end-stage myelodysplastic syndrome and renal failure on a background of ischaemic heart disease, hypertension, valvular disease, and metastatic prostate cancer. He was admitt…

general medicinehaematologydelaysystemcefuroxime
NSWhome2024-08-06

Inquest into the death of Dion Moore

29y · Male·Mixed drug toxicity, most significantly methamphetamine and buprenorphine, with …

Dion Moore, a 29-year-old Aboriginal man, died on 5–6 January 2019 from mixed drug toxicity (methamphetamine and buprenorphine), with heat and dehydration as significant contributing factors. After running out of fuel wi…

diagnosticdelaymethamphetamine
VICaged care2024-04-11

Finding into death of Irene Mary Donne

85y · Female·Complications following a fall

An 85-year-old woman with dementia died from complications of a fall sustained when pushed by another resident with dementia at an aged care facility. The autopsy revealed skull fracture, extradural haemorrhage, and rib …

geriatric medicineemergency medicinetramadol
VIChome2024-02-13

Finding into death of Child K

12y · Male·Injuries sustained in a quad bike incident (driver)

A 12-year-old boy died from injuries sustained in a quad bike accident on his family's rural property. He was riding unsupervised without parental permission when the bike collided with a drain bank, flipping and impalin…

emergency medicinesurgeryfentanyl
SAhome2023-12-06

Coroner's Finding: Cullen, Jason Mark

37y · Male·mixed drug toxicity with fentanyl as the principal agent

37-year-old Jason Cullen died from mixed drug toxicity with fentanyl as the principal agent. He had chronic idiopathic intracranial hypertension requiring multiple neurosurgeries and was prescribed opioids and benzodiaze…

neurosurgerypsychiatrycommunicationsystemfentanyl
WAhospital2023-11-17

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

2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…

A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…

intensive carepaediatricsmedicationceftriaxone
NSWhospital2023-10-31

Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…

Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…

intensive careanaesthesiadiagnosticproceduralrocuronium
QLDhospital2023-10-20

HILSLEY, Herbert

79y · Male·Pneumonia, due to or as a consequence of emphysema (chronic obstructive pulmonar…

Herbert Charles Hilsley, aged 79, died of pneumonia secondary to emphysema with contributing ischaemic heart disease while incarcerated at Rockhampton Base Hospital. He had extensive comorbidities including COPD, ischaem…

respiratory medicinecardiologysalbutamol
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