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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
QLDhospital2024-12-16

Inquest into the death of Shane Anthony May

61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…

Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory…

emergency medicinerespiratory medicineamlodipine
VIChospital2024-10-28

Finding into death of Loreta Maria Del Rossi

98y · Female·Multi-organ failure following amanita poisoning

A 98-year-old woman died from multi-organ failure following amanita (death cap) mushroom poisoning. She had foraged wild mushrooms from her garden in April 2024 without incident, then consumed mushrooms from the same loc…

toxicologyemergency medicineactivated charcoal
VIChospital2024-08-06

Finding into death of Noah Andrew Souvatzis

1y · Male·acute meningitis from Streptococcus pneumoniae, associated with diffuse brain sw…

Noah Souvatzis, a 19-month-old boy, died from Streptococcus pneumoniae meningitis on 31 December 2021 after presenting to Northeast Health Wangaratta ED on 29 December. Critical failures in his first ED presentation incl…

emergency medicinepaediatricsdiagnosticproceduralondansetron
QLDhospital2024-07-02

Non-inquest findings into the death of Child Q

2y · Female·Complications of bacterial chest infection (Staphylococcus aureus)

A 2-year-old Aboriginal and Torres Strait Islander girl died from complications of bacterial chest infection (Staphylococcus aureus) with concurrent Human metapneumovirus infection, presenting as left empyema and bilater…

emergency medicinepaediatricscommunicationamoxicillin
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
VIC2024-06-17

Finding into death of Ryleigh James Pallot

28y · Male·Chest injuries following a cliff collapse

A 28-year-old man died from chest injuries (haemothorax, bilateral pneumothoraces, rib fractures) sustained in a cliff collapse at Addiscot Beach, Victoria on 31 December 2021. While sitting under cliffs with friends dur…

ondansetron
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
NThospital2024

Inquest into the death of Road Death 27 of 2024

39y · Male·Multiple blunt force injuries due to motor vehicle collision (pedestrian), with …

A 39-year-old Aboriginal male with chronic alcohol intoxication was struck by a vehicle travelling at 79 km/h in a 60 km/h zone while crossing unsafely at an uncontrolled location. He sustained severe traumatic brain inj…

neurosurgerytrauma surgeryalcohol
NThospital2024

Inquest into the death of Road Death 60 of 2024

74y · Male·Complications of multiple blunt force injuries sustained in a motor vehicle cras…

A 74-year-old Aboriginal man died from complications of multiple blunt force injuries sustained in a single-vehicle rollover crash on Christmas Day 2024. He was driving with a blood alcohol concentration of 0.14% (three …

trauma surgeryintensive carealcohol
VICcommunity2023-12-20

Finding into death of Lachlan McMahon Cook

16y · Male·Hypoxic/ischaemic encephalopathy in the context of diabetic ketoacidosis

A 16-year-old with Type 1 Diabetes died from diabetic ketoacidosis (DKA) precipitated by acute gastroenteritis acquired while on a school trip to Vietnam. Despite reporting vomiting at 8am on 26 September 2019, Lachlan w…

endocrinologygeneral practicediagnosticcommunicationinsulin
VIChospital2023-11-24

Finding into death of Vikki Michelle Prenc

59y · Female·Asphyxial aspiration with upper airways obstruction by vomitus

Ms Prenc, a 59-year-old woman with spina bifida, died from asphyxial aspiration with upper airway obstruction by vomitus while hospitalised for urosepsis. The critical clinical issue was a Goals of Care (GOC) document co…

general practicegeneral medicinecommunicationsystemondansetron
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
VIChospital2023-08-29

Finding into death of Edward Michael Schutz

80y · Male·Complications of vertebral artery and right carotid artery vascular injuries (op…

An 80-year-old retired surgeon died from complications of vertebral artery and right carotid artery vascular injuries and cervical spine injuries sustained in a body surfing incident at Sandy Gully Beach. He was struck b…

emergency medicineneurosurgeryacetone
VIChospital2023-08-11

Finding into death of Mr H

58y · Male·aspiration pneumonia complicating sigmoid volvulus, in a man with multiple scler…

Mr H, a 58-year-old man with end-stage multiple sclerosis and recurrent sigmoid volvulus, presented to Box Hill Hospital on 25 January 2023 with abdominal pain and distension. He underwent rectal tube insertion via sigmo…

surgeryemergency medicinemorphine
VICcommunity2023-07-13

Finding into death of Christopher James Wrigglesworth

59y · Male·Multiple injuries sustained from a tree falling on a motor vehicle (driver)

Christopher Wrigglesworth, aged 59, died when a tree fell on his vehicle during severe weather. Emergency services responded promptly, but he was trapped for approximately 100 minutes before extrication. Despite resuscit…

emergency medicinetrauma surgeryondansetron
VIChospital2023-07-06

Finding into death of Michael Alan Holmes

34y · Male·effects of burns

Michael Holmes, 34, died from severe burns sustained when he re-entered a burning house attempting to rescue his son. The fire originated from clothes and towels left drying on a rack in front of an unattended wood heate…

emergency medicinetrauma surgerysystemfentanyl
TAS2023-07-05

Coroner's Finding: Crump, Damian Michael

36y · Male·Mixed prescription drug toxicity (morphine, lignocaine, amiodarone and midazolam…

Damian Crump, aged 36, was an intensive care paramedic with Ambulance Tasmania who died by suicide on 23 December 2016 by deliberately consuming fatal quantities of morphine, lignocaine, amiodarone and midazolam stolen f…

paramedicinepsychiatrysystemdelaymorphine
VIChospital2023-05-23

Finding into death of Silin Wang

25y · Female·multiple injuries

A 25-year-old woman with newly diagnosed metastatic gastro-oesophageal cancer and depression died by suicide on hospital grounds. She was admitted on 30 January 2021 after imaging showed cancer progression. Her sister di…

oncologypsychiatrycommunicationsystemdiazepam

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