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VIChospital2025-07-03

Finding into death of JV M

19y · Female·multiple injuries sustained in a train incident

JVM was a 19-year-old with major depressive disorder, anxiety, and possible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St …

psychiatryemergency medicinecommunicationsystemsertraline
WAhospital2025-06-30

Inquest into the death of Houston PEEL

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

Houston Peel, a 29-year-old man, presented to Fiona Stanley Hospital ED at 4:35 am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation fol…

emergency medicinepsychiatrycommunicationdelayolanzapine
QLDhome2025-06-25

Non-inquest findings into the death of an eight month old twin whose family was known to Child Safety

0y · Male·Severe acute dehydration and acute malnutrition

An eight-month-old boy died from severe acute dehydration and malnutrition after receiving no or minimal fluid or food intake during a three-day drug binge by his mother and her partner. Child Safety was involved with th…

paediatricsemergency medicinediagnosticsystemmethamphetamine
TAShome2025-06-24

Coroner's Finding: Infant W and Infant P

Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…

Two premature infants died from unsafe sleeping environments while in the care of their parents, despite being subject to child protection notifications. Infant W (4 months) died from asphyxia due to accidental overlay i…

paediatricspsychiatrydiagnosticcommunicationmethadone
VIChome2025-06-24

Finding into death of Jessica Geddes

27y · Female·Complications of multiple blunt force injuries

Jessica Geddes, 27, was killed by her partner Robert Rickerby through multiple blunt force injuries on 6 November 2020. The autopsy revealed extensive acute, subacute and chronic injuries inconsistent with accidental tra…

general practicepsychiatrydiagnosticsystemmethamphetamine
NSWhome2025-06-24

Inquest into the death of Jade

3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…

Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…

paediatricspsychiatrydiagnosticcommunicationquetiapine
QLDhospital2025-06-20

Inquest into the death of Christopher Glen Essery

74y · Male·Sepsis secondary to fistulating Crohn's disease and post-surgery complications f…

Christopher Essery, a 74-year-old man with complex fistulating Crohn's disease, died from sepsis following surgery on 24 January 2019. He was transferred to Princess Alexandra Hospital (PAH) on 31 August 2018 for special…

colorectal surgerygastroenterologysystemcommunication
TASaged care2025-06-16

Coroner's Finding: McDonald, Maureen June

87y · Female·Terminal exacerbation of chronic obstructive pulmonary disease; antecedent cause…

Maureen 'Kitty' McDonald, 87, died from terminal exacerbation of COPD with an antecedent sacral pressure wound infection. She was admitted to residential aged care in October 2020 with a stage-two sacral pressure injury …

geriatric medicinegeneral practicesystemcommunicationantibiotics
ACTPodcast2025-06-13

Inquiry Into The Orroral Valley Fire

On 27 January 2020, an ADF MRH-90 Taipan helicopter ignited a fire in Namadgi National Park, ACT, during Defence Assistance to the Civil Community operations. The crew made an unplanned landing in the high-danger Orroral…

communicationsystem
TASaged care2025-06-13

Coroner's Finding: de-identified OQ -2

84y · Male·Head injury - left lateral convexity acute subdural haematoma with 2mm midline s…

An 84-year-old man with Parkinson's disease and moderate dementia was admitted to a rehabilitation unit after a fall at an acute hospital. He had been assessed as high falls risk and required a patient sitter at the acut…

geriatric medicinerehabilitation medicinecommunicationsystem
WA2025-06-12

Inquest into the Death of Sam Phillip Chisholm LYNCH

27y · Male·effects of fire

Sam Lynch, aged 27, died from effects of fire while in remand at Hakea Prison on 5 March 2024. Following a dispute over undelivered canteen items, Sam set his mattress ablaze with a lighter. The response was catastrophic…

systemcommunicationdiazepam
SAhospital2025-06-11

Coroner's Finding: OHalloran, Emma Louise

48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam

A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…

cardiologygeneral practicesystemcommunicationflecainide
SA2025-06-03

Coroner's Finding: Sears, James Frank

53y · Male·disseminated malignant melanoma

A 53-year-old man died of disseminated malignant melanoma while incarcerated at Yatala Labour Prison. Initial excision of a large arm mole in November 2019 revealed Stage III melanoma. A January 2020 multi-disciplinary t…

dermatologyoncologycommunicationsystemdabrafenib
VIChospital2025-06-03

Finding into death of DRF

95y · Female·Acute intracranial haemorrhage

DRF, a 95-year-old woman with dementia, hearing impairment, mobility limitations, and mild cognitive impairment, died from acute intracranial haemorrhage following blunt head trauma. She had been living with her son UJN,…

geriatric medicineneurosurgerycommunicationsystemwarfarin
QLDhospital2025-06-02

Non-inquest findings into the death of Mr B.

42y · Male·Multiple organ failure due to iatrogenic phenol overdose due to metastatic pancr…

A 42-year-old man with metastatic pancreatic cancer died from multiple organ failure caused by iatrogenic phenol overdose during a celiac plexus block for pain management. The radiologist administered 40ml of 80% phenol …

radiologyintensive carediagnosticmedicationphenol 80%
VIChome2025-06-02

Finding into death of Christina Lackmann

32y · Female·Caffeine toxicity

32-year-old woman died from caffeine toxicity after ingesting caffeine tablets. She called 000 at 7:49 pm reporting dizziness and numbness but was triaged as non-urgent Code 3. Unable to connect with a secondary triage p…

emergency medicinetoxicologytriagesystemcaffeine
NSWhome2025-05-30

Inquest into the Death of K.P.

3y · Male·unascertained

KP was a 3-month-old with intrauterine growth restriction born to a mother with documented mental health issues and cannabis use. Despite referral to SAFE START and child protection involvement, care coordination and fol…

paediatricspsychiatrysystemcommunicationcannabis
NSWhospital2025-05-28

Inquest into the Death of Garry Small

71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …

A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…

emergency medicinegeriatric medicinemedicationdelayceftriaxone
NThospital2025-05-27

Inquest into the death of Child MS

4y · Male·Haemophilus influenzae septicaemia with superimposed respiratory tract infection

A 4-year-old previously healthy male presented to Katherine Regional Hospital on 10 September 2023 with fever and eye pain. He was examined, found to have tachycardia (HR 156) and fever (39.2°C), and diagnosed with viral…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
VIChospital2025-05-21

Finding into death of Nazlou (Helen) Danilidis

94y · Female·Complications of a fractured neck of femur sustained in an unwitnessed in-hospit…

A 94-year-old woman with significant cardiopulmonary comorbidities died from complications of a fractured femur sustained in an unwitnessed hospital fall. Despite identification as high falls risk and implementation of f…

geriatric medicinecardiologysystemcommunicationlorazepam

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