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QLDhospital2026-04-14

Inquest into the death of Francis Michael Fahey

70y · Male·Metastatic melanoma with ischaemic heart disease as a contributing condition

Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…

oncologygeneral medicinesystemdelayimmunotherapy
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
VIChospital2026-01-08

Finding into death of Linette Ann Hawkins

80y · Female·Injuries sustained in a motor vehicle collision (driver)

An 80-year-old woman died from injuries sustained in a motor vehicle collision after likely experiencing a seizure or similar medical episode while driving. She had a history of traumatic brain injury from 1972 and a doc…

neurologytrauma surgerycommunicationsystemlevothyroxine
WAhospital2025-12-05

Inquest into the Death of Leslie Charles LINTON

64y · Male·acute myocardial infarction in association with coronary artery atherosclerosis

Leslie Charles Linton, a 64-year-old man with severe triple-vessel coronary artery disease, presented to Royal Perth Hospital on 15 December 2023 with an infected foot wound and acute psychosis. Initial troponin elevatio…

cardiologypsychiatryrisperidone
VIC2025-10-07

Finding into death of Anthony George Creaton

55y · Male·Acute myocardial infarction secondary to coronary artery thrombosis due to coron…

Anthony Creaton, 55, died of acute myocardial infarction due to coronary artery thrombosis and atherosclerosis in prison custody. He presented with chest pain on 13 November 2022 (twice) and again on 14 November, but nur…

cardiologygeneral practicediagnosticcommunicationgliclazide
VIChospital2025-07-30

Finding into death of YTR

78y · Female·Complications of prolonged immobility and malnutrition in a woman with retroperi…

A 78-year-old woman with schizophrenia, depression, and undiagnosed retroperitoneal lymphoma died from septic shock complicating severe pressure ulcers, malnutrition, and dehydration. She had been immobile on a couch for…

geriatric medicineintensive caredelaysystemasenapine
QLDhospital2024-10-18

Findings into the death of John Ainsworth

68y · Male·Cerebrovascular disease

John Raymond Ainsworth, a 68-year-old prisoner, died of cerebrovascular disease following a severe stroke on 25 November 2020. He had poorly controlled Type II diabetes, hypertension, and high cholesterol. Prior to his a…

neurologyemergency medicinedelaymetformin
SAhome2024-09-13

Coroner's Finding: McKinley-Glen, Haydn James

22y · Male·neck compression due to hanging

A 22-year-old man with treatment-resistant schizophrenia died by hanging while under guardianship with special powers of detention in supported independent living. He had attempted suicide by drinking bleach one month pr…

psychiatryemergency medicinepaliperidone
NSW2024-06-20

Inquest into the death of Michael Baker

44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…

Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…

general practicepsychiatrydiagnosticcommunicationmethadone
SA2023-12-05

Coroner's Finding: Graham, Alan Leslie

79y · Male·undetermined - presumed death following vehicle breakdown while attempting to wa…

Alan Leslie Graham, 79, disappeared from Angepena Station near Leigh Creek, South Australia between 30 April and 2 May 2016. He was an experienced traveller with a keen interest in geology who frequently visited remote p…

pantoprazole
VIChospital2023-08-01

Finding into death of Michele Valentino

81y · Male·Head injury sustained in a fall

Michele Valentino, 81, died from a head injury sustained in a fall on 20 December 2019, with death occurring on 24 December 2019. A CT angiogram at 3:45pm showed worsening intraventricular haemorrhage (IVH) that was not …

emergency medicineradiologydiagnosticcommunicationaspirin
NSW2023-07-21

Inquest into the death of Reuben Button

34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…

Reuben Button, a 34-year-old Aboriginal man, died in custody from ischaemic heart disease secondary to coronary atherosclerosis. During his 5-year imprisonment, his weight increased from 86kg to 162kg despite attempts at…

psychiatrygeneral practicediagnosticsystembuvidal
QLDhospital2023-07-05

Conlon, Edgar

75y · Male·End-stage renal disease, with hypertension, ischaemic heart disease, and diabete…

Edgar Hugh Sandow, a 75-year-old First Nations man, died from end-stage renal disease while incarcerated at Princess Alexandra Hospital Secure Unit. He had multiple comorbidities including heart failure, diabetes, hypert…

nephrologycardiologyaspirin
NSWhospital2023-03-03

Inquest into the death of Irene Charlish

68y · Female·Complications of a fall with contributing factors of respiratory failure, respir…

Irene Charlish, a 68-year-old woman with longstanding schizoaffective disorder and multiple comorbidities, fell at her residential facility on 6 June 2017, sustaining a pneumothorax and rib fracture. She was admitted to …

emergency medicinepsychiatryclozapine
VIChospital2023-02-28

Finding into death of Mrs K

81y · Female·Cardiac tamponade secondary to dissection of ascending aorta

An 81-year-old woman with hypertension and hypercholesterolaemia presented to the ED with sudden-onset central chest pain radiating to the jaw. Despite appropriate initial assessment and ruling out acute coronary syndrom…

emergency medicinecardiologydiagnosticdelayaspirin
SAcommunity2023-01-31

Coroner's Finding: Bromage, Ronald

72y · Male·acute cerebral infarction complicating acute myocardial infarction

Ronald Bromage, aged 72, died from acute cerebral infarction complicating acute myocardial infarction. He presented with chest pain on 22 and 25 February 2016 to his GP, Dr P., who diagnosed costochondritis without perfo…

general practicecardiologydiagnosticdelayparacetamol/codeine
NSW2022-11-24

Inquest into death of William EPERE

43y · Male·Hanging

William Epere, aged 43, died by hanging in custody at Dawn de Loas Correctional Centre on 10 January 2019. He had been remanded in custody for 27 days following repeated breaches of a domestic violence order, despite cle…

psychiatrycorrectional healthproceduralsystemescitalopram
QLD2022-11-15

Chardon, John William

73y · Male·Coronary atherosclerosis with hypertension, diabetes mellitus, emphysema and per…

John William Chardon, a 73-year-old prisoner, died from coronary atherosclerosis with severe calcified atheroma causing >70% stenosis of coronary arteries. He presented with dizziness on 21 October 2020, which initially …

cardiologygeneral medicineamiodarone
VIChome2022-10-05

Finding into death of Fiona Lebner

57y · Female·Combined features of moderately stenosed right coronary ostium, aortic valve reg…

Fiona Lebner, a 57-year-old woman with severe intellectual disability living in a group home, died suddenly from acute cardiac arrhythmia secondary to multiple heart abnormalities including aortic valve disease, mitral v…

cardiologyvascular surgerysodium valproate
VIChospital2022-08-19

Finding into death of Ruth Ann McKenna

62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…

A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy fo…

gynaecologyanaesthesiadiagnosticsystemmetaraminol

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