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VIChomeNew2026-08-26

Finding into death of Judith Margaret Kerr

78y · Female·Multiple organ failure secondary to sepsis and renal failure due to bronchopneum…

A 78-year-old woman with cognitive impairment, depression, and complex care needs fell at home on 11 February 2022. Her sons delayed seeking medical help for 4 days, during which she developed aspiration pneumonia and wa…

emergency medicineintensive carecommunicationsystemmirtazapine
VICcommunityNew2026-08-17

Finding into death of Guy Christian Mason

48y · Male·Pulmonary thromboembolism

Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…

emergency medicinegeneral surgerydiagnosticsystemenoxaparin
SAhome2026-08-12

Coroner's Finding: Sylvia, Kate Marie

32y · Female·cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage

Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. mis…

paramedicinegeneral medicinediagnosticcommunicationoral contraceptive pill
TASaged careNew2026-08-10

Coroner's Finding: Cox, Beverley Jane

88y · Female·Cardiac failure secondary to pacemaker failure and pacemaker battery exhaustion

This case involves an 88-year-old woman with a pacemaker who became lost to follow-up after her last clinic visit in May 2019, when no follow-up appointment was arranged. Without systematic tracking between the specialis…

cardiologygeneral practicesystemcommunication
NSW2026-08-07

Inquest into the death of Amanawel Ayai

23y · Male·complications of bowel obstruction by adhesions

A 23-year-old man in lawful custody at Parklea Correctional Centre presented on 7 January 2022 with severe chest pain, abdominal pain, vomiting, and dehydration, with a significant history of previous abdominal surgery a…

correctional healthgeneral practicediagnosticcommunicationmetoclopramide
VICaged care2026-07-29

Finding into death of Rosemary Elsie Harriet Jacoby

94y · Female·Drug toxicity (baclofen, gabapentin, oxycodone, pregabalin, zolpidem)

A 94-year-old residential aged-care resident died from drug toxicity after receiving another resident's medications. An agency nurse, unfamiliar with the patient and interrupted during medication preparation, failed to p…

general practiceemergency medicinemedicationcommunicationbaclofen
WAhome2026-07-28

Inquest into the Death of Travis John WALDER

32y · Male·multiple injuries

Travis Walder, 32, died by suicide on 24 August 2023 after being struck by a train. He had schizophrenia and opioid use disorder with prior suicide attempts. On 23 August, he became acutely agitated and psychotic at his …

psychiatryemergency medicinecommunicationsystemmethamphetamine
VIChospital2026-07-27

Finding into death of Alan Gordon Wolstenholme

72y · Male·Complications of suspected upper gastrointestinal tract haemorrhage, hospital ac…

A 72-year-old man with metastatic squamous cell lung cancer and multiple serious comorbidities was admitted to Ballarat Hospital in July 2024 with lethargy, fatigue, and rapid atrial fibrillation. Due to medication chart…

cardiologyemergency medicinemedicationsystembuprenorphine
VIChospital2026-07-23

Finding into death of Vicki Karon Grigg

67y · Female·Pulmonary thrombo-embolism secondary to deep venous thrombosis, with contributin…

Vicki Grigg, 67, died from pulmonary embolism three days after discharge from Goulburn Valley Health. She had been admitted with influenza A exacerbating asthma and COPD, and received standard-dose anticoagulation prophy…

respiratory medicineemergency medicinemedicationcommunicationenoxaparin
TAScommunity2026-07-15

Coroner's Finding: Hubbard, Brady James

21y · Male·Cerebral temporal lobe uncal and cerebellar tonsillar herniation

Brady Hubbard, 21, died from traumatic brain injury with cerebral herniation after falling from an unsecured utility vehicle driven by Andrew Hilfenhaus at West Ulverstone Football Club in June 2023. While riding on the …

emergency medicineintensive carecommunicationdelayalcohol
SAhospital2026-07-14

Coroner's Finding: Rosenzweig, Colin Anthony

61y · Male·bronchopneumonia complicating cerebrovascular accident due to cardioembolism on …

A 61-year-old man with a mechanical aortic valve underwent colonoscopy requiring temporary warfarin cessation. Following the procedure, he was discharged with a plan to recommence warfarin but without clear postoperative…

general surgerycardiologymedicationcommunicationwarfarin
NSW2026-07-10

Inquest into the death of Fredrick Elrezz

32y · Male·Hanging (deliberately self-inflicted)

Fredrick Elrezz, 32, died by hanging in segregation at Parklea Correctional Centre on 25 September 2020. Arrested on 1-2 September after stabbing police in an apparent suicide-by-cop attempt, Fred explicitly stated his i…

correctional healthpsychiatrycommunicationsystem
NSW2026-07-10

Inquest into the death of CG

61y · Male·Exsanguination from sharp force injuries to both arms, dissecting the veins of t…

CG, aged 61, died in Parklea Correctional Centre on 18 May 2024 from hemorrhage due to self-inflicted sharp force injuries. The coroner found multiple clinical and system failures contributed substantially to the death. …

general practiceemergency medicinesystemcommunicationoxycodone
QLDhospital2026-07-08

Inquest into the death of Phillip Graeme Abell

51y · Male·Complications of stage 4 hepatocellular carcinoma

Phillip Graeme Abell, aged 51, died from stage 4 hepatocellular carcinoma (HCC) with underlying cirrhosis and hepatitis C infection. Imprisoned at Woodford Correctional Centre, Mr Abell was diagnosed with infiltrative HC…

hepatologygastroenterologycommunicationoxycodone
QLDhospital2026-07-07

Inquest into the death of Christopher Doughty

67y · Male·Multi-organ failure secondary to acute myocardial infarction secondary to in-ste…

Christopher Doughty, 67, was admitted to Hervey Bay Hospital on 17 September 2021 with a life-threatening gastrointestinal bleed two months after receiving coronary stents. The bleed was likely caused by dual antiplatele…

cardiologyemergency medicinecommunicationproceduralaspirin
VIChospital2026-07-01

Finding into death of HJW

69y · Female·Urosepsis secondary to anuric acute renal failure and corona radiata infarct; co…

A 69-year-old diabetic woman presented to Maroondah Hospital Emergency Department on 9 June 2024 with severe right-sided abdominal pain and vomiting. CT imaging at 10:00am confirmed emphysematous pyelitis (gas-forming ki…

emergency medicinegeneral medicinediagnosticdelayfentanyl
WAhome2026-06-29

Inquest into the Death of David William LAVARS

Male·phosphine toxicity in a man with atherosclerotic heart disease

Robert Lavars died on 6 September 2022 after deliberately ingesting aluminium phosphide tablets while under police arrest at his home in Shoalwater. He had serious health conditions including strokes, heart disease, and …

toxicologyparamedicineproceduralcommunicationaluminium phosphide
QLDcommunity2026-06-26

Inquest into the death of Wayne Thomas Kerle

68y · Male·Cardiac arrest - unascertained etiology with multiple contributing factors inclu…

Wayne Thomas Kerle, 68, was arrested at his home for cannabis possession. Queensland Ambulance Service paramedics assessed him when he reported respiratory distress but cleared him for police custody after a limited exam…

paramedicineemergency medicinediagnosticproceduraldiazepam
VIChome2026-06-24

Finding into death of Sheridan Louise Burnell

24y · Female·Mixed drug toxicity

Sheridan Burnell, 24, died from mixed drug toxicity following an intentional overdose of prescription medications (lamotrigine and quetiapine) on 2 January 2021. Her mental health care was reasonable and appropriate. The…

psychiatrygeneral practicecommunicationsertraline
QLDhome2026-06-17

Inquest into death of Steven Richard Angus

52y · Male·Gunshot wound to the chest

Steven Richard Angus, a 52-year-old veteran with severe alcohol use disorder, major depressive disorder, and generalised anxiety disorder, died from a gunshot wound inflicted by Queensland Police during a welfare check o…

emergency medicinepsychiatrysystemcommunicationalcohol
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