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VIChospital2025-10-15

Finding into death of Gary William Bruce

71y · Male·Complications following a right hepatic artery injury following an open cholecys…

A 71-year-old man with myelofibrosis and prior abdominal surgery died from complications of a right hepatic artery injury during open cholecystectomy for acute cholecystitis. The operative decision was reasonable and the…

general surgeryanaesthesiacommunicationsystem
TASaged care2025-10-14

Coroner's Finding: de-identified XT

86y · Female·Hypostatic pneumonia due to the consequences of a right pubic rami fracture and …

An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…

geriatric medicineemergency medicinediagnosticcommunication
QLDhome2025-10-10

Inquest into the death of AB

31y · Male·Hanging

31-year-old male with borderline personality disorder, alcohol use disorder, and history of self-harm died by hanging. He had multiple presentations to emergency services and mental health services from March to July 202…

psychiatrygeneral practicesystemcommunicationalcohol
VIChome2025-10-09

Finding into death of Narelle Catherine Simmons

42y · Female·Haemothorax and pneumonia in the setting of acute and chronic chest injuries and…

Narelle Simmons, 42, died from haemothorax and pneumonia secondary to rib fractures, with contributing factors of hepatic cirrhosis, chronic alcoholism, and multiple drugs (methadone, methylamphetamine, diazepam, sertral…

forensic medicinegeneral practicediagnosticcommunicationmethadone
QLDhospital2025-10-08

Inquest into the death of Janis Ellen Doherty

57y · Female·Multi-organ failure due to drug-induced liver injury caused by sodium valproate …

Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nau…

neurologyhepatologydiagnosticmedicationsodium valproate
VIC2025-10-07

Finding into death of Anthony George Creaton

55y · Male·Acute myocardial infarction secondary to coronary artery thrombosis due to coron…

Anthony Creaton, 55, died of acute myocardial infarction due to coronary artery thrombosis and atherosclerosis in prison custody. He presented with chest pain on 13 November 2022 (twice) and again on 14 November, but nur…

cardiologygeneral practicediagnosticcommunicationgliclazide
NSWhome2025-10-03

Inquest into the death of Dima Thomson

39y · Male·multiple gunshot wounds

Dima Thomson, a 39-year-old man with a history of alcohol-fuelled domestic violence incidents and mental health conditions, died from multiple gunshot wounds after police attended his home responding to a breach of an ap…

forensic medicinecommunicationsystemalcohol
QLD2025-10-01

Inquest into the death of Duke Allan Wayne Schafer

36y · Male·Ligature strangulation

Duke Schafer, 36-year-old prisoner, was murdered by fellow inmate Carl Bloomfield in May 2020 at Woodford Correctional Centre. Bloomfield strangled Schafer in an unsupervised laundry area during a period when officers we…

psychiatrypsychologysystemcommunicationbuprenorphine
QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…

emergency medicineinfectious diseasesdiagnosticdelayantacid
VIChospital2025-09-30

Finding into death of Robert Thoai Dao

73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…

A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…

paramedicineemergency medicinediagnosticprocedural
VIChospital2025-09-29

Finding into death of Baby M

0y · Female·Perinatal asphyxia

Baby M was born at 38+4 weeks gestation in poor condition at The Royal Women's Hospital on 10 November 2022 and died at 24 minutes of age from perinatal asphyxia. Autopsy findings suggested cord compression occurring 4-6…

obstetricsneonatologyproceduralcommunicationadrenaline
NSWmental health2025-09-29

Inquest into the death of BQ

23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging

BQ was a 23-year-old Aboriginal woman who died by hanging on the Paringa Ward at Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and bo…

psychiatryemergency medicinediagnosticcommunication
VIChospital2025-09-25

Finding into death of Dio Miranda Katiana Kemp

3y · Female·Streptococcus pyogenes septicaemia

A three-year-old girl with Down syndrome died from Group A Streptococcus septicaemia after a 10-day illness. She presented four times to hospital (ED and rapid review clinic) over three days with fever, rash, and diarrho…

emergency medicinepaediatricsdiagnosticcommunication
VIC2025-09-24

Finding into death of Bryan Pham

24y · Male·multiple injuries and chest compression asphyxia (train strike)

Bryan Pham, 24, died by suicide via train strike on 2 June 2020, two days after release from remand custody. He had schizophrenia, substance use disorder, and was recently incarcerated for assault and FVIO breach. While …

psychiatrycorrectional healthcommunicationsystemmethamphetamine
NSWcommunity2025-09-24

Inquest into the death of Matthew Richard Lothian

37y · Male·self-inflicted gunshot wound to the head and neck

Matthew Lothian, aged 37, died from a self-inflicted gunshot wound to the head and neck on 6 January 2021 in Wollongong. He was on medical escort from custody when he seized the firearm from Correctional Services Officer…

psychiatrycorrectional healthsystemcommunicationmethadone
VIChome2025-09-17

Finding into death of Robert John Robinson

74y · Male·Pulmonary thromboembolism in the setting of deep leg vein thrombosis

A 74-year-old man died from pulmonary thromboembolism with deep vein thrombosis 10 days after elective umbilical hernia repair. He received appropriate VTE prophylaxis (mechanical and pharmacological) intraoperatively an…

surgeryanaesthesiacommunicationenoxaparin
WAprison2025-09-16

Inquest into the Death of Owen Duker Nugget WEAZEL

41y · Male·ligature compression of the neck (hanging)

Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 August 2023. He had been r…

psychiatrypsychologysystemcommunicationamitriptyline
VICaged care2025-09-15

Finding into death of Arto Aaro Bohm

74y · Male·Sepsis secondary to infected pressure wounds (necrotising fasciitis) in a man wi…

A 74-year-old man with multiple comorbidities (diabetes, obesity, respiratory failure, mental health conditions) died from sepsis secondary to necrotising fasciitis of pressure wounds developed while in aged care. Key cl…

geriatric medicinegeneral practicesystemcommunication
SAaged care2025-09-11

Coroner's Finding: Glenn, Millicent

89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…

An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…

general practicegeriatric medicinemedicationdiagnosticgentamicin
VIChome2025-09-11

Finding into death of ZSQ

26y · Female·Multiple stab wounds

ZSQ, a 26-year-old woman, was fatally stabbed by her intimate partner MJD in April 2020 after a relationship marked by escalating family violence. Critical clinical and systemic lessons include: (1) Recognition of intima…

emergency medicinepsychiatrycommunicationsystemcocaine
18910175

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