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NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

This inquest examined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recov…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
WAhospital2026-03-26

Inquest into the Death of Sandipan DHAR

1y · Male·Complications of acute lymphoblastic leukaemia

Sandipan Dhar, 21 months old, died from undiagnosed acute lymphoblastic leukaemia (ALL) complicated by sepsis and pneumonia on 24 March 2024. After three weeks of intermittent fever, he attended his GP three times and wa…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
SAcommunity2026-03-26

Coroner's Finding: Shepley, Adam Troy

30y · Male·Unascertained; likely cardiac arrhythmia

Adam Troy Shepley, aged 30, died in police custody following restraint after climbing onto roofs while displaying drug-affected and paranoid behaviour. Post-mortem examination revealed an unascertained cause, likely a ca…

emergency medicineparamedicinediagnosticcommunicationmethamphetamine
NSWcommunity2026-03-25

Inquest into the death of Jesse Riley

31y · Male·Status epilepsy secondary to cerebral cavernoma

Jesse Riley, a 31-year-old with undiagnosed cerebral cavernoma, experienced status epilepticus triggered by an unknown cause (possibly nicotine from recent vaping). While in post-ictal delirium, he was perceived as aggre…

paramedicineemergency medicinecommunicationsystemdroperidol
NSWpolice custody2026-03-20

Inquest into the death of Phillip Walton

48y · Male·cardiac arrhythmia which occurred in the context of physical exertion and hypoxi…

Phillip Walton, a 48-year-old with schizophrenia well-managed on clozapine for nearly 20 years, suffered an acute psychotic episode likely precipitated by cannabis use at a circus. After aggressive behaviour requiring po…

emergency medicineparamedicinediagnosticcommunicationclozapine
VIChome2026-03-19

Finding into death of Aisha Natasha Khan

44y · Female·Mixed alcohol and drug toxicity (tapentadol, diazepam, mirtazapine, amitriptylin…

Aisha Natasha Khan, 44, died from mixed alcohol and drug toxicity following an intentional polypharmacy overdose with alcohol consumption. She had a history of depression, alcohol use disorder, chronic pain, and two prio…

psychiatryemergency medicinesystemdelaytapentadol
NSWhospital2026-03-19

Inquest into the death of Eve Brown

42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…

Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…

emergency medicinegeneral practicediagnosticcommunicationceftriaxone
NSWhospital2026-03-17

Inquest into the death of Gia Lam

32y · Female·Sepsis due to pyelonephritis of the right kidney due to acute and chronic cystit…

A 32-year-old Vietnamese-speaking woman died from sepsis due to pyelonephritis following premature discharge from hospital onto a midwifery support program. Multiple missed diagnostic opportunities occurred: difficulty p…

obstetricsmidwiferydiagnosticcommunication
VIChospital2026-03-13

Finding into death of Wayne Ronald Watson

61y · Male·Intracranial haemorrhage and myocardial infarct

A 61-year-old man with extensive cardiac disease collapsed at a supermarket, striking his head and losing consciousness for less than 10 seconds. Paramedics identified STEMI and administered heparin on advice from Austin…

cardiologyemergency medicinediagnosticcommunicationheparin
QLDhospital2026-03-06

Non-inquest findings into the death of Ms B

35y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to vertebro…

A 35-year-old woman presented to a rural hospital with a three-day history of collapses, slurred speech, vomiting, and abnormal eye movements. A non-contrast CT head scan was normal, and she was discharged with a diagnos…

emergency medicinegeneral practicediagnosticcommunication
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
SAhospital2026-02-26

Coroner's Finding: Taylor, Warren Richard

79y · Male·Urinary tract infection with E coli bacteraemia on a background of ischaemic hyp…

A 79-year-old man with multiple comorbidities attended Whyalla Hospital ED following a fall. Paramedics documented concerning vital signs (tachypnoea, tachycardia, low oxygen saturation, fever) and a history suggestive o…

emergency medicinegeneral practicediagnosticcommunicationtrimethoprim
NSWhospital2026-02-26

Inquest into the death of Jeremy Webb

16y · Male·Anaphylaxis due to mammalian meat allergy after tick bite, causing an acute exac…

Jeremy Webb, 16, died from anaphylaxis due to mammalian meat allergy (tick-induced) which triggered status asthmaticus. He had experienced red meat reactions since age 10 and a severe respiratory event in April 2021 that…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline
NSWcommunity2026-02-24

Inquest into the deaths of Jebriel Dandan and Seiffedine Malas

24y · Male·Multiple Traumatic Injuries sustained as a result of motor vehicle crash during …

Two young men aged 24 and 25 died in a motor vehicle crash during a police pursuit on the M4 Motorway. Police conducted a high-speed speed check (up to 232 kph in an 80 kph zone) for approximately 73 seconds without acti…

forensic medicinetoxicologyproceduralcommunicationcocaine
VIChospitalPodcast2026-02-20

Finding into death of James Harilaos Tsindos

17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis

James Tsindos, a 17-year-old with known nut allergy and mild asthma, experienced anaphylaxis after inadvertently ingesting cashews in a vegan restaurant meal on 27 May 2021. Ambulance paramedics administered two doses of…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline (epinephrine) intramuscular
QLDaged care2026-02-17

Non-inquest findings into the death of Mr G

84y · Male·Complications of fracture left humerus neck due to fall due to hyperactive delir…

An 84-year-old man with Alzheimer's disease and dementia-related behaviours developed a urinary tract infection causing acute delirium, atrial fibrillation, and multiple falls. After presenting to the emergency departmen…

geriatric medicineemergency medicinediagnosticcommunicationdonepezil
ACT2026-02-12

Inquest Into The Death Of David Wood

62y · Male·cardiac arrest caused by hypothermia following prolonged exposure to extreme col…

Captain David Wood, an experienced helicopter pilot, fell into a concealed crevasse on the West Ice Shelf in Antarctica while conducting fuel cache operations. He was exposed to extreme cold (-14°C) and remained in the c…

aviation medicineemergency medicinediagnosticsystem
SAaged care2026-02-12

Coroner's Finding: D Angelo, Adelina

88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…

An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatra…

general practicegeriatric medicinediagnosticcommunicationfurosemide
VIChospital2026-02-12

Finding into death of Kristy Ann Mitchener

45y · Female·Complications of sepsis secondary to sacral pressure wound in a woman with genet…

Kristy Ann Mitchener, a 45-year-old woman with severe intellectual disability, genetic developmental and epileptic encephalopathy, and oesophageal dysmotility, died from sepsis secondary to a sacral pressure ulcer despit…

general practiceemergency medicinesystemcommunicationantibiotics
VIChospital2026-02-11

Finding into death of Michael Robert Burns

58y · Male·Pulmonary thromboembolism complicating right calf deep venous thrombosis

Michael Burns, 58, presented to hospital with exertional chest pain and shortness of breath. He was diagnosed with stable angina and discharged home on cardiac medications. He returned the next day with dizziness attribu…

cardiologyemergency medicinediagnosticcommunicationbisoprolol

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