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QLDhospital2026-04-14

Inquest into the death of Francis Michael Fahey

70y · Male·Metastatic melanoma with ischaemic heart disease as a contributing condition

Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…

oncologygeneral medicinesystemdelayimmunotherapy
SAhospital2026-02-26

Coroner's Finding: Lowery, Nahuel Sebastian

41y · Male·Acute liver failure with contributing Castleman's disease

A 41-year-old Aboriginal man with HIV and Castleman's disease died from acute liver failure while on home detention. He had variable compliance with antiretroviral therapy, exacerbated by amphetamine use disorder and men…

infectious diseasesintensive careantiretroviral therapy
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
QLDhospital2025-08-11

Inquest into the death of John Reginald Wright

79y · Male·Complications of peripheral vascular disease with Type 2 Diabetes Mellitus, atri…

John Reginald Wright, a 79-year-old remand prisoner, died from complications of peripheral vascular disease with diabetes, atrial fibrillation, cardiomyopathy and delirium. He was transferred to Princess Alexandra Hospit…

vascular surgerygeneral medicineglicazide
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…

emergency medicineintensive carediagnosticproceduralhydromorphone
WAhospital2024-08-28

Inquest into the Death of Matthew John PICKIN

56y · Male·Complications, including sepsis, of left leg infection (operated), in a man with…

Matthew John Pickin, a 56-year-old prisoner with metastatic lung adenocarcinoma, died from sepsis complicating a left leg infection. His lung cancer was appropriately investigated following haemoptysis in October 2021, w…

respiratory medicineoncologysystemdexamethasone
VICaged care2024-01-11

Finding into death of Phyllis Joan Porter

72y · Female·Large rectal prolapse and ischaemic bowel

A 72-year-old woman with intellectual disability residing in aged care presented with a large rectal prolapse and ischaemic bowel. She was found on the floor of her room with a prolapse containing approximately 80cm of n…

emergency medicinesurgeryfluoxetine
WAhospital2023-11-02

Inquest into the Death of Bradley James Raymond STINSON

66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…

Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arteriosclerotic cardiovascular disease, pulmonary thromboembolism, and metasta…

palliative careoncologyproceduralsystemoxycodone
NSWhospital2023-09-13

Inquest into the death of Jeffrey Blundell

44y · Male·cardiogenic shock, on a background of severe tricuspid valve regurgitation, seve…

Jeffrey Blundell, a 44-year-old man with severe intravenous drug use history, died from cardiogenic shock secondary to severe tricuspid valve regurgitation caused by infective endocarditis from non-sterile injection prac…

cardiothoracic surgerycardiologyhydromorphone
QLDhospital2023-08-17

Schwartz, Thomas Edward

64y · Male·End stage liver disease due to Hepatitis C and non-alcoholic fatty liver disease

Thomas Edward Schwartz, a 64-year-old prisoner, died from end-stage liver disease due to Hepatitis C and non-alcoholic fatty liver disease. He was transferred from Wolston Correctional Centre to Princess Alexandra Hospit…

gastroenterologyhepatologyoxazepam
VIChospital2023-03-16

Finding into death of Reginald William Griggs

84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …

An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…

oncologyENT surgerycommunicationsystemhydromorphone
VIChome2022-07-20

Finding into death of Brian Kevin Scurrah

75y · Male·Complications of multiple myeloma (palliated)

Brian Kevin Scurrah, a 75-year-old man with intellectual disability living in a supported residential service, died from complications of multiple myeloma. He was diagnosed with advanced multiple myeloma in June 2021 fol…

oncologypalliative careamiodarone
WAhospital2022-02-14

Inquest into the Death of Jeffrey Lee STRETTLES

52y · Male·complications in association with advanced malignancy (hepatocellular carcinoma)…

Jeffrey Lee Strettles, a 52-year-old prisoner, died from complications of advanced hepatocellular carcinoma, end-stage cirrhosis, and generalised sepsis. He had contracted Hepatitis C in the late 1980s and was diagnosed …

gastroenterologyoncologysystemledipasvir
TAShome2021-12-21

Coroner's Finding: O'Donnell, Margaret Joy

51y · Female·Cannot be determined; likely mixed drug (including alcohol) toxicity or undeterm…

Margaret Joy O'Donnell, aged 51, died between 9-15 June 2018. The cause of death could not be determined due to decomposition, but toxicology revealed mixed drug toxicity including fatal levels of methadone and hydromorp…

general practicepsychiatrymedicationsystemoxycodone
TAShome2021-12-17

Coroner's Finding: Tilley, Jennifer May

58y · Female·undetermined; possible mixed drug intoxication and/or adrenal insufficiency

Jennifer May Tilley, aged 58, died on 8 January 2018 with an undetermined cause, though mixed drug intoxication and adrenal insufficiency were potential contributors. She had complex medical conditions requiring chronic …

general practicerheumatologysystemcommunicationpethidine
SAhospital2021-11-23

Coroner's Finding: Beahl, Raymond Saxon

81y · Male·metastatic rectal adenocarcinoma with infected necrotic sacral ulcer

Raymond Saxon Beahl, 81, died of metastatic rectal adenocarcinoma complicated by an infected necrotic sacral ulcer. He was admitted to Oakden Older Persons Mental Health Service with severe dementia-related behavioural d…

psychiatrypalliative carediagnosticcommunicationamoxicillin/clavulanate
NSWhospital2021-11-18

Inquest into the death of James Sampson DORAN

85y · Male·metastatic prostate cancer

An 85-year-old man died of metastatic prostate cancer while in custody serving a sentence for historical child sexual offences. He had declined investigation and treatment for prostate cancer when an enlarged prostate wa…

palliative caregeriatric medicinezoludex
TAShospital2020-11-26

Coroner's Finding: Kelly, Brian John

71y · Male·hydromorphone toxicity

71-year-old man with end-stage mesothelioma died from hydromorphone toxicity after receiving 20mg instead of the prescribed 2mg dose in the ED. The overdose was accidental but resulted from shocking inattention to basic …

palliative careemergency medicinemedicationsystemhydromorphone
SAhospital2020-11-03

Coroner's Finding: ALLEN Wendy Elizabeth

75y · Female·general inanition and pneumonia on a background of end-stage dementia

75-year-old woman with end-stage mixed dementia (vascular and Alzheimer's) died from general inanition and pneumonia. She was detained under a Mental Health Act Inpatient Treatment Order due to severe aggression and beha…

psychiatrygeriatric medicinehydromorphone
SAhospital2020-06-25

Coroner's Finding: ASHTON Lorraine June

78y · Female·advanced dementia (end stage)

Mrs Lorraine Ashton, aged 78, died of advanced dementia (end stage) at Repatriation General Hospital on 23 September 2017. She had Primary Progressive Aphasia diagnosed in 2014 following non-Hodgkin's lymphoma treatment.…

psychiatrygeriatric medicineoxazepam

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