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QLDhospital2026-03-31

Inquest into the death of Robyn Ann Beale

78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …

A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…

general surgeryanaesthesiadiagnosticcommunicationoxycodone
VIChome2026-03-19

Finding into death of Catherine Alison Lynch

41y · Female·Mixed drug toxicity (alprazolam, clonazepam, diazepam, methadone, metoclopramide…

Catherine Lynch, a 41-year-old nurse, died from mixed drug toxicity in July 2022 in circumstances consistent with suicide. She was experiencing severe family violence, including coercive control, threats, stalking and em…

psychiatrypsychologycommunicationsystemalprazolam
NSWhospital2026-03-19

Inquest into the death of Eve Brown

42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…

Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…

emergency medicinegeneral practicediagnosticcommunicationceftriaxone
NSW2026-03-06

Inquest into the death of Gregory Merriman

58y · Male·acute myocardial infarction caused by ischaemic heart disease

Gregory Merriman, a 58-year-old Aboriginal man, died from acute myocardial infarction caused by advanced ischaemic heart disease while in custody at Metropolitan Reception and Remand Centre on 27 December 2022. He experi…

cardiologygeneral practicediagnosticcommunicationperindopril
VIChospital2026-02-20

Finding into death of Brian Robert Dean

44y · Male·Sepsis due to Streptococcus pyogenes (Group A Streptococcus) septicaemia complic…

Brian Dean, a 44-year-old with obesity, presented to hospital on 1 July 2023 with influenza A and signs of shock (tachycardia, hypotension, elevated lactate). He was treated with fluids and discharged the next morning ap…

emergency medicineinfectious diseasesdiagnosticdelayondansetron
NThospital2026-02-10

Inquest into the death of Martin Leach

67y · Male·Congestive cardiac failure

Martin Leach, a 67-year-old man serving a life sentence, died from congestive cardiac failure with atrial fibrillation and dilated cardiomyopathy. He had consistently refused life-prolonging medical treatments and comple…

emergency medicinecardiologysystemcommunicationmorphine
VIChome2026-01-08

Finding into death of L L

34y · Female·Combined drug toxicity (gabapentin, oxycodone, tramadol, diazepam, citalopram, d…

A 34-year-old woman with complex medical history including chronic pain, sleep disorder, anxiety and PTSD died from combined drug toxicity involving gabapentin, oxycodone, tramadol, diazepam, citalopram, desmethylvenlafa…

general practicerespiratory medicinesystemcommunicationgabapentin
VIC2025-12-05

Finding into death of Jennifer Lee Hombsch

68y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian)

A 68-year-old woman with mobility limitations from congenital hip dysplasia was struck by a motor vehicle while crossing a pedestrian crossing. The driver failed to exercise proper caution when turning left at the inters…

emergency medicineparamedicineketamine
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
VIChospital2025-07-30

Finding into death of MHT

86y · Male·Complications of blunt force trauma in a man with cardiac amyloidosis and athero…

An 86-year-old man with dementia, cardiac amyloidosis and atherosclerotic cardiovascular disease died from complications of blunt force trauma sustained in an assault by his adult son. The deceased had been diagnosed wit…

emergency medicineneurosurgerysystemcommunicationondansetron
VIChome2025-07-28

Finding into death of Heather Ida Simone Calgaret

30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…

Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …

general practiceaddiction medicinemedicationdiagnosticbuprenorphine
SA2025-05-20

Coroner's Finding: Pham, Duy Ngoc

35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…

35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…

emergency medicinegeneral practicedelaycommunicationmethamphetamine
QLDaged care2025-04-17

Non-inquest findings into the death of Mr H.

89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…

An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …

geriatric medicinegeneral practicediagnosticcommunicationmacrogol
VIChospital2025-04-11

Finding into death of QB T

64y · Male·Complications of congestive cardiac failure on a background of cardiac hypertrop…

QBT, a 64-year-old man with complex medical and psychiatric history including schizophrenia, COPD, and hypertension, was admitted to Bendigo Hospital on an Assessment Order after police concerns about mental health deter…

psychiatrygeneral medicinediazepam
VIC2025-03-31

Finding into death of John David Hogarth

59y · Male·Injuries sustained in a motorcycle incident (rider)

A 59-year-old experienced motorcyclist died from injuries sustained when his motorcycle lost control on the Western Freeway near Ballan, Victoria. He was riding a roadworthy Harley Davidson when he lost balance after rid…

diazepam
VICcommunity2025-03-04

Finding into death of Andrea Dorothy Milner

55y · Female·Multiple injuries sustained in a train incident

Andrea Milner, a 55-year-old woman with cerebral palsy, depression, and anxiety, died from multiple injuries sustained when she drove her motorised wheelchair off a railway platform onto tracks at Ormond station on 23 Se…

psychiatrypsychologyescitalopram
VIChospital2025-02-27

Finding into death of Steven John Parlby

73y · Male·Complications of multiple injuries sustained in a motor vehicle incident (car vs…

A 73-year-old man with extensive medical comorbidities including severe biventricular heart failure, COPD, sleep apnoea, and hypertension experienced a medical episode while driving, causing him to cross into oncoming tr…

general practicecardiologysystemcommunicationvalsartan
VIChome2025-01-20

Finding into death of Kim Marie Bartolo

47y · Female·Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol…

Kim Bartolo, a 47-year-old woman with depression, anxiety, alcohol use disorder and chronic conditions, died from mixed drug toxicity involving multiple prescription medications. She was admitted to Brunswick Private Hos…

psychiatryorthopaedic surgerycommunicationmedicationvenlafaxine
VIChospital2025-01-02

Finding into death of Sheila Marion Quairney

68y · Female·Acute myocardial infarction and coronary artery atherosclerosis

A 68-year-old woman presented to St Vincent's Hospital emergency department with upper abdominal and left-sided chest pain following a stationary bicycle fall. Clinicians attributed her symptoms to codeine adverse reacti…

emergency medicinecardiologydiagnosticsystemparacetamol
VIChospital2025

Finding into death of TBL

81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…

An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…

psychiatrygeneral practicesystemdelayrisperidone

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