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TAShospital2024-11-26

Coroner's Finding: de-identified FG

57y · Male·partially suspended hanging

A 57-year-old man with longstanding alcohol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for orthopaedic injuries sustained from intentional jumping. He …

orthopaedic surgerypsychiatrycommunicationsystemdiazepam
NTcommunity2024-11-25

Inquest into the death of Kumarn Rabuntja, Kumanjayi Haywood, Miss Yunupingu and Ngeygo Ragurrk

Female·Domestic violence homicides: Miss Yunupiŋu—stab wound to chest; Ngeygo Ragurrk—b…

This landmark coronial finding examines four domestic violence deaths of Aboriginal women in the Northern Territory—Miss Yunupiŋu (2018), Ngeygo Ragurrk (2019), Kumarn Rubuntja (2021), and Kumanjayi Haywood (2021)—all ki…

paediatricsemergency medicinediagnosticcommunicationalcohol
VIChospital2024-11-22

Finding into death of RD Z

11y · Male·complications of bowel obstruction in the setting of chronic constipation

RDZ was an 11-year-old Aboriginal boy who died from complications of bowel obstruction secondary to chronic constipation with a fecalith. He had been under paediatric care for years with multiple admissions for bowel was…

gastroenterologypaediatric surgerydiagnosticcommunicationmacrogol
QLDhospital2024-11-20

Non-inquest findings into the death of Mr W

82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis

An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …

general medicinegeriatric medicinediagnosticcommunicationendone 2.5mg
QLDcommunity2024-11-18

Inquest into the death of Ashley Charles Washington

31y · Male·Undetermined

Ashley Washington, a 31-year-old Kamilaroi man, died after police restraint and sedation during arrest in Toowoomba. He was apprehended following a report of property theft and stabbed a police dog and officer with sciss…

emergency medicineparamedicinediagnosticcommunicationmethamphetamine
VIChome2024-11-18

Finding into death of Dean Andrew Broughton

29y · Male·Sudden Unexpected Death in Epilepsy (SUDEP)

Dean Broughton, a 29-year-old man with hyperekplexia and possible epilepsy living in an assisted living facility, was found deceased at home. Autopsy and review of medical records confirmed Sudden Unexpected Death in Epi…

neurologyemergency medicinedelay
WA2024-11-15

Inquest into the death of Kingsley Dean Garlett

32y · Male·ligature compression of the neck (hanging) in a man with methadone and methylamp…

Kingsley Garlett, aged 32, died by hanging in a maximum security prison cell on 31 July 2022. The evidence indicates his death was an impulsive response to relationship conflict with his partner revealed through prison p…

psychiatrypsychologysystemdelaymethadone
NTcommunity2024-11-15

Inquest into the death of Kumanjayi Jurrah

2y · Male·accidental drowning

A 2-year-old boy drowned at a public pool in a remote Australian community during a childcare centre excursion. Critical clinical and organisational failures contributed: no formal risk assessment was documented for the …

public healthemergency medicineproceduralsystem
WAhospital2024-11-13

Inquest into the death of Chloe Grace Tupper

31y · Female·organ failure due to anorexia nervosa

Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…

psychiatrypaediatricssystemcommunicationmirtazapine
VIChome2024-11-13

Finding into death of Noeline Michelle Dalzell

49y · Female·stab wound to the neck

Noeline Dalzell, a 49-year-old Aboriginal woman, was fatally stabbed in the neck by her partner James Fairhall on 4 February 2020 after 17 years of escalating family violence. Multiple systems failed to protect her and h…

paediatricscorrectional healthcommunicationsystem
VICcommunity2024-11-11

Finding into death of Glykeria Skalistis

70y · Female·drowning (likely), but ultimately undetermined cause

Glykeria Skalistis, aged 70, disappeared on 29-30 August 2019 and is presumed to have drowned at Schnapper Point beach. She had a long history of schizophrenia and depression, managed with antipsychotic and antidepressan…

psychiatryemergency medicinediagnosticcommunicationantidepressants
QLDhospital2024-11-08

Non-inquest findings into the death of SD

61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed

A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…

haematologypathologydiagnosticcommunicationprednisolone
NSWhome2024-11-08

Inquiry into the fire at Yankees Gap Road Bemboka

On 15 August 2018, a hazard reduction burn on private property at Yankees Gap Road, Bemboka (NSW) breached containment and spread uncontrolled into national parkland, burning approximately 19,664 hectares, destroying at …

communicationsystem
QLDcommunity2024-11-04

Inquest into the death of Damon Paul William Savage

27y · Male·Multiple gunshot wounds

Damon Savage, 27, died from multiple gunshot wounds during a police response to a domestic violence incident. He had called police while assaulting his partner, armed himself with two large knives, advanced towards offic…

psychiatryemergency medicinecommunicationsystemmethamphetamine
NSWhome2024-11-04

Inquest into the death of MR

4y · Female·hypoxic brain injuries

A 4-month-old girl died from hypoxic brain injury following an unexplained, unnatural restriction of oxygen on 13 May 2017. She was found unresponsive at home and despite resuscitation, suffered irreversible brain damage…

paediatricspathologydiagnosticdelay
TAShome2024-10-29

Coroner's Finding: Bird, Helen Frances

43y · Female·asphyxia due to hanging

Helen Bird, aged 43, was found hanging in her garage in July 2010. While initially ruled suicide, a reopened coronial investigation found the coroner believes she was killed by her husband Mark Bird. Evidence showed Hele…

general practicepsychiatrydiagnosticprocedural
NSW2024-10-24

Inquest into the death of Fiona Goodberg

36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…

Fiona Goodberg, a 36-year-old nurse with prior OCD history, died by falling from Landslide Lookout on 29 October 2020. She had experienced severe postpartum obsessive-compulsive disorder (OCD) following her daughter's bi…

psychiatrygeneral practicediagnosticcommunicationescitalopram
TAShome2024-10-23

Coroner's Finding: Earl, Kathleen May

58y · Female·Complications of poorly controlled type 2 diabetes

Ms Kathleen Earl, aged 58, died from complications of poorly controlled type 2 diabetes in June 2022. She had an intellectual disability and received support from IHCS (Individual Support Worker) since 2005. Critical def…

general practiceendocrinologysystemcommunicationryzodeg
NSW2024-10-23

Inquest into the death of Alen Imbrisak

47y · Male·Sudden cardiac death in association with COVID-19 infection

Alen Imbrisak, a 47-year-old man incarcerated at Junee Correctional Centre, died on 26 January 2022 from sudden cardiac death in association with COVID-19 infection. He tested positive on 25 January 2022 during a centre-…

respiratory medicineemergency medicinecommunicationsystemmethadone
WAcommunity2024-10-22

Inquest into the Death of Karl Jonathan TURNER

49y · Male·combined drug toxicity

Karl Turner, a 49-year-old man with schizoaffective disorder and chronic polysubstance use, died from combined drug toxicity (heroin, morphine, pregabalin, methylamphetamine, and cannabis). He was managed on a Community …

psychiatryintensive caresystemdelaymorphine

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