Coronial
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SAhospital2026-04-23

Coroner's Finding: Wilson, Charles Thomas

85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …

An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …

cardiologygeriatric medicinemedicationcommunicationmetoprolol
VIChome2026-03-04

Finding into death of Marko Kelentric

73y · Male·Effects of fire

A 73-year-old man died in a residential fire in rural Victoria. He was found unresponsive in his bedroom and declared deceased after fire rescue and paramedic resuscitation attempts. Autopsy confirmed death from smoke in…

systemamitriptyline
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
VIChome2025-12-04

Finding into death of Raymond John Flaherty

57y · Male·Mixed drug toxicity (heroin, methadone, benzodiazepines including novel benzodia…

Raymond John Flaherty, a 57-year-old Wurundjeri man with longstanding opioid and benzodiazepine dependence, died from mixed drug toxicity involving heroin, methadone, prescribed diazepam, unprescribed benzodiazepines inc…

addiction medicinegeneral practicesystemcommunicationheroin
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
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
WA2025-06-12

Inquest into the Death of Graham John BUTLER

76y · Male·out-of-hospital cardiac arrest in a man with coronary artery atherosclerosis and…

Graham John Butler, aged 76, died from out-of-hospital cardiac arrest secondary to coronary artery atherosclerosis and diabetes whilst imprisoned at Acacia Prison. He had significant cardiac history including prior myoca…

cardiologyemergency medicinebenzydamine
VIChome2025-06-05

Finding into death of Caine David Knight

26y · Male·Cardiomegaly in a man with Prader-Willi syndrome

Caine David Knight, aged 26, died from cardiomegaly with right ventricular hypertrophy in the context of Prader-Willi syndrome and severe obesity. He had a complex medical history including obesity hypoventilation syndro…

cardiologyrespiratory medicinequetiapine
TAScommunity2025-04-24

Coroner's Finding: de-identified FG

53y · Male·Acute myocardial infarction due to triple vessel atherosclerosis and thrombosis …

A 53-year-old man with chest pain on exertion presented to his GP in March 2022. Initial investigations (blood tests, chest X-ray) were ordered but follow-up was delayed until July 2022. A cardiology referral was made, a…

cardiologygeneral practicediagnosticdelayrosuvastatin
VIChospital2025-03-12

Finding into death of Robin Albert Banks

90y · Male·Pneumonia complicating injuries sustained in a motor vehicle incident

A 90-year-old man died from pneumonia following injuries sustained in a motor vehicle collision. He had multiple reportable medical conditions including atrial fibrillation, coronary artery disease, chronic kidney diseas…

general medicinegeriatric medicinecommunicationsystemdigoxin
TAShospital2024-10-18

Coroner's Finding: Long, Leonard

73y · Male·subdural haematoma from fall

Leonard Athol Long, a 73-year-old on warfarin for mechanical mitral valve replacement, fell twice during hospitalization for urinary tract infection. He was on SMZ-TMP antibiotics, which interact significantly with warfa…

general medicineemergency medicinediagnosticsystemwarfarin
QLDhospital2024-08-13

Non-inquest findings into the death of RJH

70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide card…

A 70-year-old woman with complex cardiac history including heart failure, paroxysmal atrial fibrillation, and coronary atherosclerosis presented with urinary tract infection and atrial fibrillation on Christmas Day 2021.…

cardiologyemergency medicinediagnosticmedicationflecainide
QLD2024-06-18

Inquest into the deaths of Shiralee Deanne Tilberoo and Vlasta Wylucki

Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…

Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…

cardiologyaddiction medicineproceduralcommunicationdiazepam
VIChospital2024-06-14

Finding into death of Joshua Paul Coates

49y · Male·Acute myocardial infarction complicating prosthetic valve thrombosis in a man wi…

Joshua Paul Coates, aged 49, died from acute myocardial infarction complicating prosthetic valve thrombosis following mechanical aortic valve replacement. Post-mortem examination revealed a large blood clot obstructing h…

cardiothoracic surgerycardiologycommunicationsystemwarfarin
VIChospital2024-05-06

Finding into death of Errol Leslie Solly

67y · Male·Ischaemic heart disease; coronary artery atherosclerosis (stented)

A 67-year-old man with extensive cardiac history presented to the ED with recurrent ischaemic-sounding chest pain. Despite multiple episodes of chest pain during admission, initial ECGs and troponins were normal. Followi…

emergency medicinecardiologydiagnosticcommunicationmorphine
VIChospital2024-03-19

Finding into death of Craig Ashley Hill

53y · Male·Cardiomegaly in a man with obesity and chronic liver disease

Craig Ashley Hill, a 53-year-old man with multiple comorbidities including obesity, chronic liver disease with cirrhosis, cardiomegaly, hypertension, diabetes, and mental health conditions, died suddenly in hospital from…

psychiatrycardiologydiazepam
VIChome2024-03-06

Finding into death of Maurice Wayne Matthews

70y · Male·Mechanical asphyxia from being crushed under car

A 70-year-old retired diesel mechanic died from mechanical asphyxia after being crushed under a vehicle he was working on at home. He had positioned a jack on rocky, sloped gravel terrain, which became unstable and slid,…

sertraline
NSW2024-03-06

Inquest into the death of WM

59y · Male·Hanging

A 59-year-old man serving a life sentence died by hanging in his segregation cell at Lithgow Correctional Centre on 2-3 April 2020. He had a history of depression, anxiety, and a prior serious self-harm attempt in 2010 r…

psychiatryforensic medicinesystemmirtazapine
VIChome2024-01-10

Finding into death of Ya (Cindy) Zhao

28y · Female·Effects of fire

Ya Zhao, 28, died from effects of fire in her residential unit on 22 July 2022. She had schizophrenia with a history of mental health crises, depression, self-harm and suicidal ideation. She was living independently with…

psychiatryemergency medicineamisulpride
TAShome2024

Coroner's Finding: Heraghty, Susanna Elizabeth

68y · Female·mixed prescription drug toxicity (oxycodone, metoprolol, diazepam)

Ms Heraghty, a 68-year-old woman with multiple comorbidities including obesity (BMI 47.3), atrial fibrillation, COPD, and severe chronic pain, died from mixed prescription drug toxicity (oxycodone, metoprolol, diazepam) …

orthopaedic surgeryanaesthesiaoxycodone

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