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VIChome2026-04-17

Finding into death of Simon Christopher Gaskill

50y · Male·unascertained

Simon Gaskill, aged 50, was found deceased in sand dunes at Ocean Grove Beach in April 2022 after sleeping rough for months. He had been discharged from hospital in December 2021 following treatment for severe alcohol wi…

emergency medicinegeneral medicinecommunicationsystemalcohol
VIChospital2025-12-01

Finding into death of Larelle Sheridan Dean

51y · Female·Multiorgan failure in the setting of WHO Class III obesity, chronic excessive al…

A 51-year-old woman with WHO Class III obesity, chronic alcohol consumption, and anaemia died of multiorgan failure following admission with community-acquired pneumonia and respiratory failure. She presented with abdomi…

general medicineemergency medicinehydromorphone
VICcommunity2025-09-01

Finding into death of Ms FSZ

32y · Female·Compression of the neck

FSZ, a 32-year-old woman, was killed by her intimate partner NLU through compression of the neck (strangulation) on 24 April 2019. This coronial finding identifies multiple systemic failures in family violence response a…

psychiatryemergency medicinediagnosticcommunicationolanzapine
SAhospital2025-07-03

Coroner's Finding: Provis, Adam James

50y · Male·in-hospital cardiac arrest on a background of seizures and atheroembolic cerebro…

A 50-year-old man with bipolar affective disorder, hypertension, anxiety, depression and history of alcohol abuse died from in-hospital cardiac arrest on a background of seizures and atheroembolic cerebrovascular disease…

psychiatryneurologythiamine
VIChospital2025

Finding into death of Ms NXA

54y · Female·neck compression secondary to hanging

Ms NXA, a 54-year-old woman with complex mental health conditions including depression, CPTSD, and anxiety, presented to hospital after a suicide attempt by overdose on 9 August 2021. She was experiencing severe tinnitus…

emergency medicinepsychiatrydiagnosticcommunicationdiazepam
NSW2024-09-17

Inquest into the death of Robert Phair

37y · Male·Cardiomegaly giving rise to lethal cardiac arrhythmia in the setting of drug tox…

37-year-old Robert Phair died in Parklea Correctional Centre from cardiomegaly causing lethal cardiac arrhythmia in the setting of drug toxicity. He was placed in detoxification requiring four-hourly clinical observation…

addiction medicineemergency medicinediagnosticcommunicationheroin
WAhospital2023-04-17

Inquest into the Death of Edward Ivan AFRICH

64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …

Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…

respiratory medicinecardiologycommunicationsystemthiamine
NSWmental health2022-09-16

Inquest into the death of S B

81y · Male·cardiac arrest following neck compression due to hanging

An 81-year-old man with a history of alcohol dependence, paranoid delusions regarding his wife's infidelity, and possible vascular dementia was admitted to mental health facilities involuntarily after discharging a firea…

psychiatrygeriatric medicinediagnosticcommunicationolanzapine
WAhospital2022-01-25

Inquest into the Death of Carole LIVESEY

54y · Female·unascertained

Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…

psychiatrygeneral medicinecommunicationproceduralfluoxetine
QLDhospital2021-02-24

Fullerton, Robert Martin

59y · Male·Disseminated carcinoma on a background of emphysema

Robert Fullerton, a 59-year-old Aboriginal man from Palm Island, died from disseminated carcinoma while remanded in custody at Townsville Correctional Centre. He presented with abdominal pain on 5 December 2018, was diag…

oncologycardiologyprazosin
VIC2020-09-18

Finding into death of Michael James McBain

44y · Male·Subarachnoid haemorrhage due to ruptured anterior communicating artery aneurysm

A 44-year-old man died in prison from subarachnoid haemorrhage due to ruptured anterior communicating artery aneurysm. He had pre-existing hypertension, depression, anxiety, and chronic pain. While at the remand centre, …

forensic medicinepsychiatrymirtazapine
VICcommunity2019-10-09

Finding into death of Michael Travis Kidd

35y · Male·Clozapine toxicity

A 35-year-old Aboriginal man with schizophrenia and alcohol use disorder died from clozapine toxicity while residing at a non-clinical peer recovery facility. He presented with psychiatric distress on 10 December 2016, r…

psychiatryforensic medicinecommunicationsystemclozapine
NSWhospital2019-06-14

Inquest into the death of Melissa King

33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…

Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraem…

intensive careendocrinologydiagnosticcommunicationglycoprep
QLD2019-05-08

Malone, Terrence Michael

54y · Male·incised wound to the neck

Terrence Michael Malone, a 54-year-old man with a 20-year history of bipolar affective disorder, PTSD, and alcohol dependence, died by suicide in Brisbane Correctional Centre on 8 November 2014, three days after re-incar…

psychiatryemergency medicinediagnosticcommunicationalcohol
NSWhospital2019-03-01

Inquest into the death of Stephen Kline

51y · Male·Pulmonary thromboemboli due to deep vein thrombosis on a background of a leg bur…

Stephen Kline, a 51-year-old Aboriginal man, died from pulmonary thromboembolism due to deep vein thrombosis following a leg burn wound sustained when NSW Police deployed a taser during a confrontation on 8 March 2016. H…

plastic and reconstructive surgerypsychiatrydiagnosticsystemheparin
NSW2018-07-13

Inquest into the death of Sony William Tran-Bui

33y · Male·complications of acute peritonitis caused by rupture of a duodenal ulcer

Sony William Tran-Bui, aged 33, died from acute peritonitis caused by a ruptured duodenal ulcer while in custody at Silverwater Correctional Centre in November 2013. The death was not preventable given the sudden, unexpe…

gastroenterologyemergency medicinecommunicationsystemdiazepam
WAhome2018-03-22

Inquest into the Death of Aileen Helen QUARTERMAINE

60y · Female·effects of fire in a woman with alcohol effect

A 60-year-old woman with chronic paranoid schizophrenia died in a domestic fire on 26 July 2014. The day before, her son sought help from police and mental health services after noticing signs of mental health deteriorat…

psychiatryemergency medicinecommunicationdiagnosticpaliperidone
QLD2018-01-24

Bernard, Peter Matthew

42y · Male·Coronary artery atheroma with arrhythmia

A 42-year-old Indigenous man with acquired brain injury and epilepsy died suddenly in custody from coronary artery atherosclerosis causing arrhythmia. He exercised vigorously the day before death, became pale and sweaty …

emergency medicineforensic medicinesodium valproate
SAhospital2017-11-17

Coroner's Finding: CAMERON George William

76y · Male·pneumonia and exacerbation of chronic obstructive airway disease

George William Cameron, aged 76, died from pneumonia and exacerbation of chronic obstructive airway disease at Noarlunga Hospital. He was admitted with acute alcohol withdrawal, confusion, and respiratory symptoms. A Lev…

psychiatrygeneral medicinesalbutamol
VIChospital2017-07-18

Finding into death of Lynsie Maree Everett

36y · Female·Complications of pneumonia and pulmonary emphysema with bullae formation; respir…

A 36-year-old woman with congenital chest wall abnormality, scoliosis, and difficult intubation history presented to a rural hospital with community-acquired pneumonia and sepsis. She had multiple 'red flag' indicators o…

emergency medicineinfectious diseasesdiagnosticsystemsalbutamol

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