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VIChome2025-07-28

Finding into death of GVY

43y · Female·Head and neck injuries

GVY, aged 43, was fatally attacked by her husband MJN with an axe and knife on 3 December 2022 after she initiated separation. MJN had a documented history of coercive control, physical violence, jealousy, and financial …

systemdelay
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
VIChome2025-07-28

Finding into death of Aluel Ajak

9y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian)

Aluel Ajak, a 9-year-old girl with autism spectrum disorder, severe developmental delay, and moderate intellectual disability, died from injuries sustained when struck by a motor vehicle after absconding from her home. S…

paediatricsdisability medicinesystemdelayclonidine
VICaged care2025-07-24

Finding into death of Silvie Marion Burton

89y · Female·Acute upper airway obstruction by food bolus

An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significant discrepancies between reported actions and actua…

geriatric medicineemergency medicineproceduraldelaycitalopram
VICmental health2025-07-24

Finding into death of Mr SWX

32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity

A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …

psychiatryemergency medicinemedicationcommunicationolanzapine
NSWcustodial setting (correctional facility) with death at hospital2025-07-23

Inquest into the death of James Cunneen

60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…

James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…

general practiceinfectious diseasesdiagnosticmedicationpantoprazole
WAhospital2025-07-22

Inquest into the Death of Samaan Salah Tilmiz ELSAMIN

21y · Male·unascertained

Samaan Salah Tilmiz Elsamin, a 21-year-old with treatment-resistant schizophrenia, moderate-to-severe intellectual disability (IQ 57), and unpredictable violent behavior, died on 9 November 2022 at Joondalup Health Campu…

psychiatryintensive caresystemdelayclozapine
QLDhospital2025-07-22

Inquest into the death of Hazel Mary Ritchie Brodie

79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…

A 79-year-old woman with severe COPD and heart failure presented with two weeks of nausea and vomiting. She was diagnosed with left ventricular failure (EF 33%) on day 1 of admission. Two cardiologists had key roles: Dr …

cardiologyrespiratory medicinediagnosticcommunicationfurosemide
VIChospital2025-07-22

Finding into death of Helena Zoe Broadbent

32y · Female·Head injuries in a motor vehicle incident

Helena Zoe Broadbent, a 32-year-old pregnant Aboriginal woman, died from severe head injuries sustained when her partner William Wilson drove off in a vehicle while she was partially inside it, causing her to be ejected …

emergency medicinetrauma surgerycommunicationsystemcannabis
VICcommunity2025-07-17

Finding into death of John Michael Jurdeczka

62y · Male·Hypoxic ischaemic encephalopathy complicating cardiac arrest in setting of acute…

John Michael Jurdeczka, a 62-year-old man with autism, intellectual disability, and dysphagia, died from hypoxic ischaemic encephalopathy following cardiac arrest caused by acute upper airway obstruction from a food bolu…

speech pathologygeneral practicecommunicationsystemmorphine
QLDhome2025-07-15

Inquest into the death of Daniel Thomas Wright

8y · Male·prematurity-associated lung and bowel disease

Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associate…

neonatologypaediatricsdiagnosticcommunication
TAS2025-07-14

Coroner's Finding: Penney, Raymond

64y · Male·chest and abdominal injuries due to being crushed by a regrowth tree

Raymond Penney, 64, died when struck by a regrowth tree during mechanical felling operations in a commercial forestry coupe. The old growth tree (68m, 50-60 tonnes) was being felled using excavator-assisted mechanical pu…

occupational and environmental healthproceduralcommunication
QLDhospital2025-07-14

Non-inquest findings into the death of a two year old girl whose family was known to Child Safety

2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection

A two-year-old girl died from complications of severe iron-deficiency anaemia and COVID-19 infection. She had significant feeding difficulties, took almost exclusively milk and yoghurt, and was profoundly anaemic with po…

paediatricsemergency medicinediagnosticdelaymethamphetamine
VIChospital2025-07-14

Finding into death of Baby Sidney

0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…

Baby Sidney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell …

obstetricsneonatologydiagnosticcommunicationoxytocin
WAcommunity2025-07-09

Inquest into the Death of Travis Barry Mark Kimberly HART

33y · Male·Heat stroke (environmental exposure) in a man with methylamphetamine effect

Travis Hart, 33, died from heat stroke with methylamphetamine effect after abandoning a vehicle during a police intercept in bushland near Kalgoorlie on 25 December 2022. He became separated from companions and was found…

emergency medicineforensic medicinedelaycommunicationmethamphetamine
WA2025-07-08

Inquest into the Death of Tim Alan LOOKER

29y · Male·ligature compression of the neck (hanging)

Tim Looker, aged 29, died by suicide in Bunbury Regional Prison on 3 October 2023 by hanging from a bedsheet attached to a protruding bolt in his cell. Tim had ADHD diagnosed since childhood (previously prescribed dexamp…

general practicepsychiatrysystemcommunicationdextroamphetamine
NSW2025-07-08

Inquest into the death of SF

19y · Male·Hanging

SF, a 19-year-old remand inmate with no prior custodial or mental health history, died by hanging in Goulburn Correctional Centre 18 hours after requesting protective placement due to safety fears. He had expressed depre…

correctional healthpsychiatrycommunicationsystem
NTcommunity2025-07-07

Inquest into the death of Kumanjayi Walker

19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …

Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…

emergency medicinegeneral practicediagnosticprocedural
TAS2025-07-04

Coroner's Finding: de-identified CF

24y · Male·blunt trauma and drowning due to intentional jumping from Tasman Bridge

A 24-year-old male international student and graduate employee experienced his first acute psychotic episode in December 2022, triggered by workplace stress and unsubstantiated beliefs about colleague manipulation. Initi…

psychiatryemergency medicinedelaycommunicationolanzapine
VIC2025-07-04

Finding into death of Brent Reker

35y · Male·Hanging

Brent Reker, a 35-year-old prisoner with extensive history of suicide attempts (including hanging, overdose, and self-harm), died by hanging in Forbes Unit at Ravenhall Corrections Centre on 12 December 2019, approximate…

psychiatryemergency medicinecommunicationsystemmethadone

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