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VIChospital2026-02-05

Finding into death of Max Peter McKenzie

15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…

Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…

emergency medicineparamedicinedelaycommunicationadrenaline
TAScommunity2026-01-13

Coroner's Finding: Joshua James Tyrrell

28y · Male·Multiple head, facial and spinal injuries sustained in a single vehicle motorbik…

Joshua Tyrrell, 28, died from multiple head, facial and spinal injuries sustained in a motorbike crash on the Brooker Highway. He was riding at excessive speed and failed to maintain steering control through a bend. Toxi…

general practiceemergency medicinemedicationcommunicationdiazepam
NSW2025-12-08

Inquest into the death of Benjamin Cullen

41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…

Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from P…

neurologyemergency medicinemedicationsystemlevetiracetam
VIC2025-11-10

Finding into death of Andrew Phillip John Kursinskis

57y · Male·Complications following food aspiration in a man with multiple co-morbidities

Andrew Kursinskis, a 57-year-old man with intellectual disability, dysphagia, autism, epilepsy and pica, died from complications following aspiration of chicken schnitzel while living in supported disability accommodatio…

speech pathologyemergency medicinesystemcommunicationlevetiracetam
VIC2025-10-29

Finding into death of David James Klingberg

55y · Male·Complications of traumatic head injury sustained in a workplace incident (pallia…

David Klingberg, a 55-year-old experienced pile testing engineer, died from traumatic head injury sustained when an auxiliary line hook on a piling rig struck him in the face at a construction site. The hook became jamme…

emergency medicineintensive caresystemmorphine
VIChome2025-09-02

Finding into death of Noel John Biggs

66y · Male·Undetermined (natural causes)

A 66-year-old man with multiple chronic conditions including Parkinson's disease, spastic gait syndrome, cognitive impairment, atrial fibrillation, and swallowing difficulties died at his supported disability accommodati…

general practiceforensic medicinelevetiracetam
VIC2025-08-06

Finding into death of Brian Matthew McDonald

69y · Male·Haemopericardium secondary to ischaemic heart disease

Brian Matthew McDonald, a 69-year-old man with autism, intellectual disability, and epilepsy living in specialist disability accommodation, died from haemopericardium secondary to ischaemic heart disease. He collapsed in…

cardiologyforensic medicinelevetiracetam
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
VIC2025-07-14

Finding into death of Jennifer Mary Clayden

61y · Female·Complications of Down's syndrome, epilepsy and advanced dementia

Jennifer Clayden, 61, with Down's syndrome, epilepsy and advanced dementia, died in Specialist Disability Accommodation on 9 May 2024 from complications of her underlying conditions. She had been transitioned to comfort-…

general practicepalliative carebuprenorphine
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
VIChospital2025-04-30

Finding into death of Margaret Ann Day

66y · Female·Ischaemic brainstem stroke

Margaret Ann Day, a 66-year-old Specialist Disability Accommodation resident with undifferentiated hereditary ataxia, intellectual disability, and dysphagia, presented to the Emergency Department on 26 November 2024 with…

neurologyemergency medicinelevetiracetam
VICmental health2025-02-27

Finding into death of Judith Mary Pollard

73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…

Judith Pollard, a 73-year-old woman with an extensive mental health history, was voluntarily admitted to Shepparton Private Hospital on 1 June 2023 following acute depression and paranoia. Despite her family informing st…

psychiatryemergency medicinesystemcommunicationamitriptyline
TASaged care2025-01-24

Coroner's Finding: Sheedy, Alan Noel

86y · Male·Traumatic closed head injury suffered in a fall

Alan Noel Sheedy, 86 years old, died from traumatic closed head injury sustained in a fall at a residential aged care facility. He had been admitted for respite care following previous falls and was assessed as moderate …

geriatric medicineneurologylevetiracetam
VIChospital2025-01-08

Finding into death of Mark Ruth

50y · Male·Sepsis of unknown organism in respiratory

Mark Ruth, a 50-year-old NDIS participant with cerebral palsy, intellectual disability, chronic dysphagia, and obstructive sleep apnoea, died from sepsis of unknown respiratory organism. He had experienced declining heal…

emergency medicinerespiratory medicinesodium valproate
VICaged care2025-01-06

Finding into death of C M

55y · Male·Diabetic ketoacidosis

CM, a 55-year-old man with severe congenital disabilities and Type 2 Diabetes, died from diabetic ketoacidosis while residing in a disability support facility. In the week preceding death, he experienced reduced appetite…

general practiceemergency medicinediagnosticlevetiracetam
VIC2024-12-16

Finding into death of Caroline Monique Hall

52y · Female·Spinal injuries sustained in falls in a woman with multiple medical comorbiditie…

Caroline Monique Hall, a 52-year-old woman with intellectual disability, epilepsy, schizophrenia, and multiple comorbidities living in supported disability accommodation, died from spinal injuries sustained in falls. She…

general practiceemergency medicinediagnosticdelaymorphine
VIC2024-11-12

Finding into death of Master K

2y · Male·Drowning

Master K, a two-year-old, drowned in a hotel pool after falling from a step into the deeper adult pool section. He remained unnoticed underwater for over nine minutes while his mother was distracted by her mobile phone, …

communicationsystemmorphine
QLDhospital2024-11-08

Non-inquest findings into the death of SD

61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed

A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…

haematologypathologydiagnosticcommunicationprednisolone
VICmental health2024-09-30

Finding into death of Erol Elmas

31y · Male·undetermined

Erol Elmas, a 31-year-old man with schizoaffective disorder, died in custody at Thomas Embling Hospital on 30 November 2022. The cause of death remains undetermined despite thorough pathological investigation. Mr Elmas w…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
TAShome2024-08-09

Coroner's Finding: Mansell-Moore, Codie

17y · Male·epileptic seizure complicating idiopathic epilepsy

17-year-old Codie Mansell-Moore died from epileptic seizures on 10 December 2018. An ambulance was called at 6:09am while he was seizing, but paramedics staged around the corner and did not enter his home for 48 minutes …

emergency medicineparamedicinecommunicationsystemlevetiracetam

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