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VIChospitalNew2026-07-01

Finding into death of Baby H

0y · Male·traumatic head injury due to instrumental vaginal delivery of a term infant

Baby H died on 24 March 2019, one day after birth, from traumatic head injuries sustained during an instrumental vaginal delivery using Neville Barnes forceps on a baby in occipito-posterior position. Critical clinical l…

obstetricsgeneral practicecommunicationprocedural
SAcommunityNew2026-06-25

Coroner's Finding: Nan Lesley Walker, Ian Rex Walker and Suzanne Mary Skeer

[77, 80, 55]y · ["female", "male", "female"]·Multiple injuries from motor vehicle collision

A motor vehicle collision on the Princes Highway near Suttontown killed three adults when a 16-year-old driver with significant neurological conditions momentarily lost concentration while ascending a hill. The driver ha…

general practicepaediatricssystemcommunication
VIChomeNew2026-06-24

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
VIChomeNew2026-06-23

Finding into death of Kaylah Veronica Sarah Woollard

25y · Female·Mixed drug consumption (pregabalin, oxycodone, desmethylvenlafaxine, aripiprazol…

Kaylah Veronica Sarah Woollard, age 25, died from mixed drug toxicity in the context of significant natural disease. She had WHO Class III obesity (BMI 94.5), cardiac hypertrophy, and mental health conditions (depression…

general practicepsychiatrycommunicationpregabalin
NThome2026-06-19

Inquest into the death of RL

17y · Male·Suicide by self-inflicted hanging

RL was a 17-year-old Alice Springs teenager who died by suicide while under Northern Territory mental health services' care. Critical clinical lessons emerged: failure to inform his mother about mental health deteriorati…

psychiatrypsychologycommunicationdiagnostic
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
QLDaged careNew2026-06-09

Non-inquest findings into the death of Mr B (1 of 3 linked pressure injury cases)

86y · Male·Multiorgan failure due to neurological failure due to Alzheimer's dementia

An 86-year-old man with advanced Alzheimer's dementia developed multiple pressure injuries while residing in aged care. A Stage 1 sacral pressure wound rapidly deteriorated to Stage 4 over two weeks despite appropriate a…

geriatric medicinepalliative carecommunicationsystem
QLDaged careNew2026-06-09

Non-inquest findings into the death of Mr M (2 of 3 linked pressure injury cases)

82y · Male·Multiorgan failure due to neurological failure due to Parkinson's disease with a…

Mr M, aged 82, with advanced Parkinson's disease and dementia, developed severe pressure injuries while in residential aged care. A significant sacral pressure wound went undetected until mid-December 2023 and rapidly de…

general practiceemergency medicinediagnosticcommunicationcefalexin
QLDaged careNew2026-06-09

Non-inquest findings into the death of Mr H (3 of 3 linked pressure injury cases)

87y · Male·Multiorgan failure due to sepsis due to skin failure, underlying vascular dement…

An 87-year-old man with vascular dementia and stroke-related quadriplegia developed a sacral pressure injury in a residential aged care facility in December 2023. Despite care interventions, the wound rapidly deteriorate…

general practicepalliative carediagnosticcommunicationantibiotics
TAS2026-06-03

Coroner's Finding: Brown, Nicholas, Wiki, Toni, Winwood, Matthew and Kemp, Belinda

Male, female, male, female·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …

Joint inquest into four deaths of individuals prescribed opioid replacement therapy by Dr J. between September 2016 and August 2017: Nicholas Shane Brown (35), Toni Lee Wiki (38), Matthew Wayne Winwood (47), and Belinda …

addiction medicinegeneral practicediagnosticmedicationmethadone
VIChome2026-05-29

Finding into death of Baby R

0y · Male·Perinatal hypoxia

Baby R, born at 39 weeks 6 days via planned homebirth with private midwives, died from perinatal hypoxia on day 6 of life. The mother had significant obstetric risk factors: previous emergency caesarean section, macrosom…

obstetricsmidwiferydiagnosticcommunication
WAhome2026-05-27

Inquest into the Death of Martin Carl QUITERIO

59y · Male·Multiple injuries

Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…

psychiatrygeneral practicesystemcommunicationhaloperidol
VICcommunity2026-05-14

Finding into death of A Q

61y · Male·Ischaemic heart disease secondary to coronary artery atherosclerosis

AQ, a 61-year-old motorsport racer, died from ischaemic heart disease secondary to coronary artery atherosclerosis while competing at Phillip Island Grand Prix Circuit on 23 November 2024. In April 2024, he underwent ste…

cardiologygeneral practicecommunicationprocedural
VICaged care2026-05-06

Finding into death of Cornelia Groot

87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…

An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…

geriatric medicineemergency medicinediagnosticcommunicationoxycodone
WA2026-04-28

Inquest into the Death of Corey Desmond DEVREE

41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…

Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…

psychiatrygeneral practicediagnosticcommunication
VIChospital2026-04-28

Finding into death of Ronald William Beaumont

74y · Male·Acute myocardial infarction complicated by multiple organ failure

Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…

cardiologyorthopaedic surgerymedicationcommunicationaspirin
VIC2026-04-22

Finding into death of Natasha Stojkoski

38y · Female·Multiple injuries sustained when struck by a train

Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…

psychiatryoccupational and environmental healthsystemcommunicationescitalopram
NSWhome2026-04-21

Inquest into the death of Michael

28y · Male·In keeping with Hanging

A 28-year-old man with a history of depression, anxiety, and previous self-harm died by hanging during a police response to a domestic violence incident. Police attended after his sister reported he had breached an ADVO …

emergency medicineparamedicinesystemcommunicationvenlafaxine
VIChome2026-04-17

Finding into death of Harrison William Ladd

25y · Male·Combined drug toxicity

Harrison William Ladd, 25, died from combined drug toxicity involving clonazepam, dexamphetamine, codeine, diazepam and pholcodine. He had complex mental health and substance use disorder requiring specialist addiction c…

general practicepsychiatrymedicationcommunicationclonazepam
VICcommunity2026-04-15

Finding into death of LX

31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)

A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …

addiction medicinepsychiatrymedicationsystemmethadone
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