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VIC2022-03-08

Finding into death of Dylan James Charlton-Smith

25y · Male·Hypoxic ischaemic brain injury due to hanging

Dylan Charlton-Smith, aged 25, died by hanging while in custody at Fulham Correctional Facility. A stressful visit from his partner preceded his death by approximately 50 minutes. A correctional officer identified distre…

psychiatryemergency medicinediagnosticcommunication
WAhospital2022-03-03

Inquest into Death of Van Tho NGUYEN

59y · Male·metastatic lung cancer, with palliation

Van Tho Nguyen, a 59-year-old remand prisoner with metastatic lung cancer, died of natural causes in a private hospital palliative care setting. He had been a lifelong smoker who developed advanced adenocarcinoma with bo…

oncologypalliative caresystemcommunicationchemotherapy agents
VIChospital2022-02-28

Finding into death of H YR

77y · Female·Haemoperitoneum following cholecystectomy

A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication bu…

general surgeryintensive carediagnosticdelaywarfarin
VIChospital2022-02-25

Finding into death of Joseph Cardona

49y · Male·haemopericardium secondary to ruptured aortic dissection

Joseph Cardona, 49, died from ruptured aortic dissection with haemopericardium. He presented to the ED twice within 24 hours with severe central chest pain radiating to jaw, neck, and back, associated with hypertension. …

emergency medicinecardiologydiagnosticcommunicationoxycodone
NSWhospital2022-02-25

Inquest into the death of Carley METCALFE

41y · Female·unable to determine

Carley Metcalfe, aged 41, was found deceased in the Brunswick River in November 2017, three weeks after disappearing. She had presented to Lismore Base Hospital on 1-2 November 2017 with acute psychosis related to schizo…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
WAmental health2022-02-25

Inquest into the Death of Jordan James WILLIAMS

20y · Male·head and neck injuries sustained when struck by train

Jordan James Williams, 20, died after being struck by a train following two absconsions from Kalgoorlie Health Campus mental health unit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Crit…

psychiatryemergency medicinesupervisioncommunicationolanzapine
TAS2022-02-24

Coroner's Finding: Scott, Paul Stephen

61y · Male·asphyxial death due to hanging

Paul Stephen Scott, aged 61, died by hanging while on leave from psychiatric inpatient care. He had been admitted to Spencer Clinic on 11 January 2018 with suicidal ideation and complex psychiatric presentation. Despite …

psychiatrygeneral practicesystemcommunicationvenlafaxine
VIChome2022-02-23

Finding into death of Mark Edward Elliott

58y · Male·Shotgun wound to the neck

Mark Edward Elliott, a 58-year-old prominent lawyer, died by suicide on 13 February 2020 following a shotgun wound to the neck. He was experiencing significant occupational and legal stress related to protracted proceedi…

general practiceemergency medicinediagnosticcommunicationzolpidem
VICcommunity2022-02-18

Finding into death of Roger David Batchelor

57y · Male·Hypoxic ischaemic encephalopathy secondary to prolonged downtime due to upper ai…

A 57-year-old man with intellectual disability and a documented history of choking died from hypoxic ischaemic encephalopathy following airway obstruction by food at a day activities program. Despite having a choking man…

general practicespeech pathologycommunicationsystempantoprazole
NSWcommunity2022-02-18

Inquest into the death of SP

36y · Male·hanging

A 36-year-old man died by hanging on 10 July 2018 after leaving his home in Blacktown, NSW. His partner called Triple Zero after 30 minutes, reporting concern for his welfare and that he was acting strangely, restless, a…

emergency medicineparamedicinecommunicationsystem
VICaged care2022-02-15

Finding into death of Melissa Cunningham

44y · Female·Complications of a lung abscess with contributing factors of Down's syndrome and…

Melissa Cunningham, a 44-year-old woman with Down's syndrome and severe obesity, died from complications of a lung abscess. She required a CPAP machine for sleep apnoea, prescribed and monitored by Western Health since 2…

respiratory medicinegeriatric medicinesystemcommunication
SA2022-02-09

Coroner's Finding: Curran, Michael Anthony

62y · Male·metastatic hepatocellular carcinoma

Michael Anthony Curran, a 62-year-old prisoner, died from metastatic hepatocellular carcinoma in 2015. He had been diagnosed with hepatitis C in 2005, which is a significant risk factor for liver cancer. A liver biopsy i…

hepatologygastroenterologydiagnosticsystemribavirin
NSW2022-02-09

Inquest into the death of IM

37y · Male·Sharp force injuries of the neck and left arm

A 37-year-old male remanded in custody at Cessnock Correction Centre died by suicide on 3 September 2019 from self-inflicted sharp force injuries to the neck and left arm. He had been in custody for 44 days following cha…

forensic medicinepsychiatrycommunication
TAShospital2022-02-08

Coroner's Finding: KN - deidentified

0y · Male·global hypoxic ischaemic encephalopathy

A term breech baby was born at Launceston General Hospital following a traumatic vaginal delivery with instrumental assistance after failed initial extraction attempts. The infant suffered severe hypoxic-ischaemic enceph…

obstetricsmidwiferydiagnosticdelay
WA2022-02-04

Inquest into the Death of Robert William ROMAN

55y · Male·Subdural haematoma in a man with diabetes mellitus and chronic kidney disease (r…

A 55-year-old Aboriginal man with end-stage renal disease, diabetes, ischaemic heart disease and COPD died from a spontaneous subdural haematoma while undergoing haemodialysis in prison custody. He presented with headach…

nephrologyemergency medicinesystemcommunicationaspirin
NSWmental health2022-02-01

Inquest into the death of Camilla MARGOLIS

34y · Female·multiple blunt force injuries

Camilla Margolis, 34, died by suicide at Echo Point Lookout in the Blue Mountains hours after discharge from mental health inpatient care. She had complex borderline personality disorder with chronic suicidality across 2…

psychiatryemergency medicinecommunicationsystemmirtazapine
NSWhospital2022-02-01

Inquest into the death of Ivan CHRISTOV

70y · Male·complications of chronic obstructive pulmonary disease and ischaemic heart disea…

A 70-year-old man with end-stage COPD, ischaemic heart disease, and obstructive sleep apnoea collapsed in his prison cell and was transferred to hospital in respiratory distress. Despite having documented 'not for resusc…

emergency medicinerespiratory medicinecommunicationdelay
VIChome2022-01-31

Finding into death of Leeanne Matheson

52y · Female·Mixed drug toxicity (methadone, pregabalin, valproic acid, benzodiazepines)

A 52-year-old woman with chronic pain, epilepsy, and opioid dependence died from mixed drug toxicity after prescribed methadone, pregabalin, valproic acid, and benzodiazepines. She was admitted to Box Hill Hospital on 12…

addiction medicinegeneral practicemedicationcommunicationmethadone
TAScommunity2022-01-28

Coroner's Finding: AZ 2022 TASCD 60

16y · Male·Multiple blunt traumatic injuries from fall from height

A 16-year-old boy with depression and suicidal ideation was discharged from an inpatient adolescent mental health facility in Victoria after 20 days. Two days later, he died by suicide at a cliff location he had previous…

psychiatrycommunicationdiagnosticfluoxetine
NThospital2022-01-25

Inquest into the death of Josef Lear

80y · Male·metastatic oesophageal cancer

Josef Lear, an 80-year-old prisoner, died of metastatic oesophageal cancer at the Royal Darwin Hospital Hospice on 7 March 2021. He presented with progressive dysphagia, cough, and weight loss in mid-2020, which was appr…

oncologygastroenterologycommunicationsystemibuprofen

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