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VIC2025-11-10

Finding into death of Andrew Phillip John Kursinskis

57y · Male·Complications following food aspiration in a man with multiple co-morbidities

Andrew Kursinskis, a 57-year-old man with intellectual disability, dysphagia, autism, epilepsy and pica, died from complications following aspiration of chicken schnitzel while living in supported disability accommodatio…

speech pathologyemergency medicinesystemcommunicationlevetiracetam
VIChospital2025-11-10

Finding into death of Jason Hosier

39y · Male·mixed drug toxicity (methadone, benzodiazepines, olanzapine, zopiclone)

Jason Hosier, a 39-year-old man with complex mental health and substance use history, died from mixed drug toxicity following discharge from Sunshine Hospital. He was subject to an inpatient temporary treatment order and…

emergency medicinepsychiatrycommunicationsystemmethadone
VIChome2025-11-04

Finding into death of Kon Maximos

62y · Male·Shotgun injury to the head

Kon Maximos, aged 62, died from a self-inflicted shotgun wound to the head on 15 October 2023. He was in acute interpersonal crisis following marital separation, family estrangement over infidelity, and police interventi…

psychiatrypsychologydiagnosticcommunicationmirtazapine
NSWcommunity2025-10-31

Inquest into the disappearance and suspected death of Sana Salman

34y · Female·not able to be determined - body not found

Sana Salman, a 34-year-old woman with bipolar disorder and schizoaffective disorder, went missing on 1 September 2022 after being discharged from Northern Beaches Hospital on 22 August 2022. She had been admitted for a p…

psychiatrysystemcommunicationclozapine
VIC2025-10-28

Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for the management of sep…

Christopher McIntosh, a 54-year-old man with type 2 diabetes, died from respiratory failure secondary to sepsis originating from an infected foot ulcer while incarcerated at Hopkins Correctional Centre. The coroner found…

correctional healthgeneral medicinecommunicationsystem
VIChospital2025-10-28

Finding into death of Jean Elizabeth Crocker

90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …

A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …

emergency medicinegeneral medicinemedicationdiagnosticwarfarin
VIChome2025-10-28

Finding into death of HCG

39y · Female·Unascertained

A 39-year-old woman experiencing intimate partner violence was assaulted by her partner on 31 January 2021 and died approximately 5 hours later. The assault caused significant blood loss; however, the medical cause of de…

forensic medicinepaediatricssystemcommunicationmethamphetamine
VIChospital2025-10-28

Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …

Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarce…

infectious diseasesvascular surgerydiagnosticsystemantibiotics
WAcommunity2025-10-24

Inquest into the Suspected Death of Guido MICHEL

54y · Male·unascertained cause

Guido Michel, a 54-year-old electrician with longstanding mental health issues including depression, ADHD, and previous suicide attempts, disappeared in late January 2022 after entering State Forest near Flint, WA with c…

psychiatrygeneral practicesystemcommunicationdextroamphetamine
NTPodcast2025-10-24

Inquest into the death of Ebony Thompson

1y · Female·hypoxic brain injury caused by pressure to the neck from entrapment on a loop-to…

Ebony Thompson, aged 22 months, died from hypoxic brain injury caused by neck entrapment in a loop-topped chickencoop gate at a childcare centre. She became trapped while standing on a tricycle attempting to view chicken…

paediatricsemergency medicinesystemcommunication
QLDhospital2025-10-24

Non-Inquest findings into the death of Ms G

76y · Female·Head injury comprised of subdural haematoma, subarachnoid haemorrhage with brain…

A 76-year-old woman died from complications of a severe head injury sustained in a motor vehicle collision. She was initially managed conservatively at a regional hospital, but her condition deteriorated markedly at 9pm …

neurosurgeryemergency medicinecommunicationdelay
QLDhospital2025-10-23

Inquest into the death of Shirley Elizabeth Haggett

78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…

78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…

anaesthesiaplastic and reconstructive surgerysystemdiagnosticmidazolam
SAcommunity2025-10-20

Coroner's Finding: Kennedy, John Douglas

65y · Male·Ischaemic heart disease on a background of hypertension

John Kennedy, 65, died from ischaemic heart disease with hypertension on 16 April 2020 after a 24-minute delay in ambulance dispatch. He called triple zero at 00:19 with severe chest pain and difficulty breathing (Priori…

emergency medicinecardiologycommunicationsystematenolol
NSWmental health2025-10-20

Inquest into the Death of JSZ

66y · Male·Multiple blunt force injuries

JSZ, a 66-year-old forensic patient with chronic paranoid schizophrenia, died by suicide while on unsupervised day leave from Cumberland Hospital's Bunya Unit on 20 September 2023. He jumped from a cliff at Queen Elizabe…

psychiatryproceduralcommunicationzyprexa relprevv
NSWhospital2025-10-20

Inquest into the death of BR

1y · Unknown·unascertained

A 12-month-old infant suffered unexpected cardiac arrest at home nine days after receiving routine MMR, meningococcal, and pneumococcal vaccinations. He presented to Manning Base Hospital on 27 July 2020 with fever (38.5…

emergency medicineintensive carecommunicationsysteminfanrix hexa
SAcommunity2025-10-17

Coroner's Finding: Hall, Robert Lloyd

66y · Male·multiple injuries sustained in motor vehicle collision

A 66-year-old cyclist was struck and killed from behind by a driver with left absolute homonymous hemianopia (left-sided visual field loss) who was not scanning to compensate for his disability. The driver had suffered a…

neurosurgeryneurologysystemcommunication
QLDhome2025-10-17

Inquest into the death of Alexandria Catherine Forrester

39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…

A 39-year-old woman with opioid dependency died from cardiac arrest caused by methadone toxicity. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatmen…

addiction medicinegeneral practicediagnosticmedicationmethadone
VIChospital2025-10-17

Finding into death of Rachel Frances Piskun

42y · Female·Pneumonia, underlying severe cerebral palsy

Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…

emergency medicinegeneral medicinediagnosticmedicationmorphine
VIChome2025-10-16

Finding into death of Ms YPM

27y · Female·Hanging

Ms YPM, a 27-year-old woman with a long history of borderline personality traits, depression, anxiety and eating disorder, died by hanging on 17 May 2020. In the preceding two weeks, she presented to Alfred Hospital foll…

psychiatryemergency medicinecommunicationdelayagomelatine
QLD2025-10-15

Inquest into the passing of ATJ

43y · Male·Hanging

A 43-year-old First Nations man died by hanging while remanded in custody for domestic violence offences. Initial risk assessments on admission were adequate—a psychologist appropriately assessed him as not requiring enh…

psychiatrypsychologycommunicationsystemamitriptyline
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