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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
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
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
TAShome2024-10-23

Coroner's Finding: Earl, Kathleen May

58y · Female·Complications of poorly controlled type 2 diabetes

Ms Kathleen Earl, aged 58, died from complications of poorly controlled type 2 diabetes in June 2022. She had an intellectual disability and received support from IHCS (Individual Support Worker) since 2005. Critical def…

general practiceendocrinologysystemcommunicationryzodeg
VIC2024-02-12

Finding into death of Maahi Tukapua

73y · Male·Acute on chronic renal failure and multi-factorial encephalopathy in a man with …

A 73-year-old man with significant comorbidities (cirrhosis, dilated cardiomyopathy, chronic kidney disease) died in prison from acute-on-chronic renal failure, hepatic encephalopathy, and multiorgan failure. He was init…

cardiologynephrologymorphine
NTcommunity2024

Inquest into the death of Road Death 13 of 2024

77y · Male·Blunt force head and chest injuries from motor vehicle collision

A 77-year-old male with a history of seizures (2017, 2023) died from blunt force head and chest injuries sustained in a motor vehicle collision on 10 March 2024. The vehicle travelled at 157 km/h approaching a red traffi…

neurologycardiologysystemlamotrigine
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
VICaged care2022-10-06

Finding into death of Vittorina Ipsa

92y · Female·Clozapine toxicity in a lady with terminal lung carcinoma

A 92-year-old woman with terminal lung cancer died from clozapine toxicity after receiving medication intended for another resident. An Enrolled Nurse preparing the medication trolley inadvertently placed another residen…

palliative caregeriatric medicinemedicationsystemclozapine
TAScommunity2020-07-17

Coroner's Finding: Lyons, Matthew Clayton

47y · Male·mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam and diazepam)

Matthew Clayton Lyons, a 47-year-old man with longstanding schizophrenia, severe anxiety, and substance abuse history, died from mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam, diazepam). He had expre…

psychiatrygeneral practicecommunicationsystemquetiapine
VIC2019-12-05

Finding into death of Serafina Pirrottina

57y · Female·Complications of muscular dystrophy

A 57-year-old woman with longstanding muscular dystrophy and newly diagnosed cardiomyopathy died from complications of her underlying condition. She became acutely unwell overnight at her residential support facility wit…

respiratory medicineemergency medicinerosuvastatin
TASaged care2018-10-30

Coroner's Finding: Dent, Freda Lillian Florence

85y · Female·ischaemic heart disease due to stenosis of coronary bypass grafts

An 85-year-old woman with significant cardiac history (prior coronary artery bypass graft) presented with gastrointestinal symptoms. Her GP ceased rosuvastatin without direct communication to nursing staff. Care staff id…

general practicegeriatric medicinecommunicationsystemrosuvastatin
VIChospital2018-02-19

Finding into death of Margaret Ann Yeomans

79y · Female·Rhabdomyolysis in a woman with multiple myeloma and renal impairment

Margaret Ann Yeomans, aged 79, died from rhabdomyolysis in the context of multiple myeloma and chronic renal impairment. A critical medication error occurred when rosuvastatin 40mg was dispensed instead of her prescribed…

haematologynephrologymedicationcommunicationrosuvastatin
QLDcommunity2016-02-05

Cooper, Paul James - Non-inquest findings

41y · Male·Hanging

Paul Cooper, a 41-year-old man with bipolar disorder, died by hanging in August 2015, eleven days after psychiatric review. He had recently commenced Isotretinoin for severe acne, which coincided with development of para…

psychiatrygeneral practicecommunicationsystemisotretinoin
SAaged care2015-08-27

Coroner's Finding: BALIAN Arsho

83y · Female·right middle cerebral artery infarct/stroke

Mrs Arsho Balian, an 83-year-old woman with dementia, schizophrenia, diabetes and recurrent UTIs, suffered a right middle cerebral artery stroke while resident in aged care under a guardianship order. She was appropriate…

geriatric medicineneurologyadalat
SA2014-11-28

Coroner's Finding: MAYGER John Christopher

58y · Male·Ischaemic and hypertensive heart disease

John Christopher Mayger, aged 58, died of ischaemic and hypertensive heart disease while in custody at Adelaide Pre-release Centre. He had a significant cardiac history including two previous myocardial infarctions with …

cardiologyemergency medicinerosuvastatin

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