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QLDcommunity2026-06-26

Inquest into the death of Wayne Thomas Kerle

68y · Male·Cardiac arrest - unascertained etiology with multiple contributing factors inclu…

Wayne Thomas Kerle, 68, was arrested at his home for cannabis possession. Queensland Ambulance Service paramedics assessed him when he reported respiratory distress but cleared him for police custody after a limited exam…

paramedicineemergency medicinediagnosticproceduraldiazepam
VIChome2026-06-24

Finding into death of Sheridan Louise Burnell

24y · Female·Mixed drug toxicity

Sheridan Burnell, 24, died from mixed drug toxicity following an intentional overdose of prescription medications (lamotrigine and quetiapine) on 2 January 2021. Her mental health care was reasonable and appropriate. The…

psychiatrygeneral practicecommunicationsertraline
VICcommunity2026-03-23

Finding into death of PCH

14y · Female·Drowning in a person with epilepsy

PCH, a 14-year-old girl in out-of-home care with a history of epilepsy, drowned in a river while washing her hair during a family camping trip. She had experienced increased seizure frequency in October-November 2024, pr…

paediatricsneurologylamotrigine
VICaged care2026-01-16

Finding into death of F M

40y · Female·Sudden unexpected death in epilepsy (SUDEP) in a woman with schizophrenia

FM, a 40-year-old woman with epilepsy and schizoaffective disorder, died from sudden unexpected death in epilepsy (SUDEP) at her disability group home. She had been prescribed periciazine (Neulactil) five days before dea…

neurologypsychiatrysystempericiazine
VIChospital2025-12-08

Finding into death of Jamie Lee Argent

38y · Male·Diabetic ketoacidosis secondary to pyelonephritis in a man with insulin dependen…

A 38-year-old man with insulin-dependent diabetes, partial blindness, gastroparesis, seizures, chronic kidney disease and peripheral vascular disease died from diabetic ketoacidosis precipitated by pyelonephritis. He had…

emergency medicineendocrinologylamotrigine
QLDhospital2025-07-15

Inquest into the death of Errol George Radan

83y · Male·left middle cerebral artery cerebrovascular accident

An 83-year-old male prisoner died from a left middle cerebral artery stroke on 26 October 2022, seven days after presenting with acute stroke symptoms. Mr Radan had atrial fibrillation and was prescribed dabigatran for a…

neurologyemergency medicinedabigatran
VIChospital2025-07-03

Finding into death of JV M

19y · Female·multiple injuries sustained in a train incident

JVM was a 19-year-old with major depressive disorder, anxiety, and possible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St …

psychiatryemergency medicinecommunicationsystemsertraline
VIChospital2025-05-26

Finding into death of Shawn James Farlech

47y · Male·Pneumonia

Shawn Farlech, a 47-year-old man with acquired brain injury from childhood encephalitis living in specialist disability accommodation, died from pneumonia with sepsis. He presented with fever on 8 April and was initially…

general medicineintensive caresodium valproate
VIC2025-05-14

Finding into death of Quang Vinh Truong

40y · Male·Unascertained; probable SUDEP (Sudden Unexpected Death in Epilepsy) - natural ca…

A 40-year-old man with severe Lennox-Gastaut Syndrome and intellectual disability died unexpectedly in his sleep at a supported disability accommodation facility. He was found in a position consistent with having had a s…

neurologyforensic medicineclobazam
VIChome2025-04-11

Finding into death of EDH

32y · Female·mixed drug toxicity including phenobarbitone

A 32-year-old woman with borderline personality disorder and depression died by intentional self-administration of pentobarbitone (Lethabarb) accessed from her workplace. She had experienced extensive family violence in …

psychiatrypsychologysystemcommunicationpentobarbitone
VIC2025-03-14

Finding into death of Aaron Matthew Forte

24y · Male·Sudden unexpected death in epilepsy (SUDEP)

Aaron Forte, a 24-year-old man with epilepsy, Jacob's XXY Syndrome, intellectual disability, and schizophrenia, died of sudden unexpected death in epilepsy (SUDEP) while in specialist disability accommodation. He was fou…

neurologygeneral practicelamotrigine
VIChome2025-02-27

Finding into death of Shayn Nathan Darmanin

43y · Male·Mixed drug toxicity (methadone, synthetic cannabinoids (5f-cumyl-pinaca and cumy…

Shayn Darmanin, a 43-year-old man with epilepsy, died from mixed drug toxicity involving methadone, synthetic cannabinoids, olanzapine, and duloxetine. He had a significant history of substance abuse, family violence off…

toxicologypsychiatrymethadone
NSWcommunity2024-12-18

Inquest into the death of Olivia Gilffillan

23y · Female·unascertained

Olivia Gilfillan, aged 23, died between 1–5 February 2018 after nine years of psychiatric treatment for anorexia nervosa, obsessive-compulsive disorder, schizoaffective disorder, and borderline personality disorder. She …

psychiatryemergency medicinesystemclozapine
VIChospital2024-09-26

Finding into death of FH C

11y · Male·Sepsis

An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…

emergency medicinepaediatricsdiagnosticcommunicationrisperidone
ACThospital2024-07-25

Inquest Into The Death Of Katherine Aurelia Alexander

34y · Female·multiple drug toxicity

Katherine Alexander, a 34-year-old woman with chronic suicidality and complex mental health conditions including bipolar II disorder, borderline personality disorder, and PTSD, died from multiple drug toxicity on 7-8 Feb…

psychiatryemergency medicinecommunicationsystemdosulepin
WAmental health2024-07-19

Inquest into the Death of Phillip Benjamin VELTMAN

49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…

Phillip Veltman, 49, died of unascertained cause (likely cardiac arrhythmia with terminal aspiration) while an involuntary psychiatric patient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on…

psychiatryemergency medicinecommunicationsystemketamine
ACTcommunity2024-06-17

Inquest Into The Death Of Catherine Maree Broadbent

39y · Female·multiple drug toxicity (etizolam and carisoprodol as major components)

Catherine Broadbent, 39, died from multiple drug toxicity involving benzodiazepines (etizolam, carisoprodol) sourced from the dark web, in the context of chronic borderline personality disorder and complex PTSD with life…

psychiatryemergency medicineetizolam
VICmental health2024-02-27

Finding into death of Sidarthan Gajaharan

26y · Male·Craniocervical injuries following a train collision (pedestrian)

Sidarthan Gajaharan, a 26-year-old with treatment-resistant schizophrenia, died by suicide after being struck by a train while on unescorted ground leave from an involuntary mental health admission. He had been hospitali…

psychiatryrehabilitation medicinecommunicationdelayclozapine
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
NTcommunity2024

Inquest into the death of Road Death 13 of 2024

77y · Male·Blunt force head and chest injuries from motor vehicle collision

A 77-year-old male with a history of seizures (2017, 2023) died from blunt force head and chest injuries sustained in a motor vehicle collision on 10 March 2024. The vehicle travelled at 157 km/h approaching a red traffi…

neurologycardiologysystemlamotrigine

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