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TASaged care2024-10-22

Coroner's Finding: Whish-Wilson, Leslie Bruce

76y · Male·hospital-acquired pneumonia, age-related frailty, consequences of left neck of f…

Leslie Bruce Whish-Wilson, 76, sustained a fall in his aged care room in January 2024, leading to a right femoral neck fracture requiring surgical repair. Post-operatively, he developed hospital-acquired pneumonia compli…

geriatric medicineorthopaedic surgerysystemdelay
QLDaged care2024-10-22

Non-inquest findings into the death of MH, an aged care resident

98y · Female·Sepsis due to sacral pressure ulcer complicated by osteomyelitis against a backg…

A 98-year-old woman with dementia and multiple comorbidities died from sepsis secondary to a sacral pressure ulcer that progressed to osteomyelitis while in residential aged care. The coroner identified systemic clinical…

geriatric medicinegeneral practicediagnosticsystemwarfarin
NSWcommunity2024-10-22

Inquest into the death of Cecilia Devine

41y · Female·Cause of death could not be established due to advanced decomposition

Cecilia Devine, a 41-year-old woman with bipolar disorder, was last seen alive on 6 September 2018 in Katoomba, NSW. Her body was discovered in the Upper Cascade Dam in March 2019, with aerial imaging suggesting death oc…

forensic medicinepsychiatrysystemdelaycannabis
QLDhospital2024-10-18

Findings into the death of John Ainsworth

68y · Male·Cerebrovascular disease

John Raymond Ainsworth, a 68-year-old prisoner, died of cerebrovascular disease following a severe stroke on 25 November 2020. He had poorly controlled Type II diabetes, hypertension, and high cholesterol. Prior to his a…

neurologyemergency medicinedelaymetformin
NSW2024-10-17

Inquest into the death of Kevin Edwards

41y · Male·Unable to be ascertained

41-year-old male with schizophrenia/drug-induced psychosis and methamphetamine use died following police restraint on M5 motorway. Admitted to Shellharbour Hospital 10-30 May 2022 for psychotic behaviours and assault all…

psychiatryemergency medicinediagnosticcommunicationmethamphetamine
TAShospital2024-10-11

Coroner's Finding: Vieth, Karl Heinz

92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…

A 92-year-old man with complex cardiac history was admitted to Royal Hobart Hospital with chest pain and atrial fibrillation. He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, …

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NSWhospital2024-10-11

Inquest into the death of AX

45y · Female·Multiple blunt force injuries

A 45-year-old woman with acute psychotic illness attended Prince of Wales Hospital ED on 4 August 2020 after presenting to police with persecutory delusions. She was assessed by mental health and medical clinicians who a…

emergency medicinepsychiatrydiagnosticcommunication
TAShospital2024-10-10

Coroner's Finding: Hill, James Fredrick

74y · Male·small intestinal ischaemia caused by aortic atherosclerosis

A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clea…

emergency medicineorthopaedic surgerydiagnosticcommunication
QLDaged care2024-10-10

Non-inquest findings into the death of Diane Margaret Crowther

76y · Female·multiple organ failure due to abdominal wall cellulitis (surgically treated)

Mrs Crowther, a 76-year-old obese woman with multiple comorbidities in residential aged care, died from multiple organ failure secondary to abdominal wall cellulitis. A critical care failure occurred when an old dressing…

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VICcommunity2024-10-04

Finding into death of T K

18y · Female·Mixed drug toxicity

TK, an 18-year-old woman with borderline personality disorder, chronic suicidality, and a history of childhood trauma, died from mixed drug toxicity following intentional overdose. She had multiple psychiatric admissions…

psychiatrygeneral practicesystemdelaytramadol
VICmental health2024-09-30

Finding into death of Erol Elmas

31y · Male·undetermined

Erol Elmas, a 31-year-old man with schizoaffective disorder, died in custody at Thomas Embling Hospital on 30 November 2022. The cause of death remains undetermined despite thorough pathological investigation. Mr Elmas w…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
VIChospital2024-09-26

Finding into death of FH C

11y · Male·Sepsis

An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…

emergency medicinepaediatricsdiagnosticcommunicationrisperidone
QLDaged care2024-09-19

Non-inquest findings - a resident

85y · Male·Heat stroke

An 85-year-old man with dementia, diabetes, and aortic stenosis died from heat stroke after spending 2 hours 18 minutes unmonitored in an unsheltered outdoor garden area at a residential aged care facility. The resident …

geriatric medicineemergency medicinesystemcommunication
VICPodcast2024-09-19

Finding into death of George Diamond

18y · Male·complications of acute on chronic subdural haemorrhage (operated) in the setting…

George Diamond, 18, died from acute-on-chronic subdural haemorrhage sustained during boxing sparring on 18 February 2019. He had suffered a head injury during sparring on 25 October 2018, presenting with headache, nausea…

general practiceemergency medicinediagnosticdelayparacetamol
SA2024-09-13

Coroner's Finding: Mortess, Noel Allen

75y · Male·End stage myelodysplastic syndrome and end stage renal failure on a background o…

A 75-year-old man died in prison custody from end-stage myelodysplastic syndrome and renal failure on a background of ischaemic heart disease, hypertension, valvular disease, and metastatic prostate cancer. He was admitt…

general medicinehaematologydelaysystemcefuroxime
NSWPodcast2024-09-12

Inquest into the death of Andrew Seton

24y · Male·multiple injuries

Andrew Seton, an experienced 24-year-old backcountry skier, died on 3 September 2022 following an accidental fall while skiing alone at Watsons Crags in Kosciuszko National Park in icy conditions. He was not reported mis…

systemcommunication
ACThospital2024-09-11

Inquest Into The Death Of Baby X

0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…

Baby X, born at Canberra Hospital after a prolonged labour, died at age 2 days from injuries sustained during birth. Two interlinked pathologies contributed to death: hypoxic-ischemic encephalopathy (HIE) from prolonged …

obstetricsneonatologydiagnosticcommunication
QLDhomePodcast2024-09-11

Inquest into death of ABC (a pseudonym)

Unknown·VAD oral substance toxicity; underlying conditions: ischaemic heart disease, emp…

An elderly person (ABC) died from self-administering a voluntary assisted dying (VAD) oral substance that had been prescribed for their spouse but not collected for return after the spouse died. ABC was grieving, suffere…

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VIC2024-09-05

Finding into death of Russell Leslie James Hewat

33y · Male·Aspiration pneumonia in the setting of recent COVID-19 infection

Russell Hewat, a 33-year-old man with autism, Down syndrome, intellectual disability, and dysphagia, died from aspiration pneumonia following COVID-19 infection. He was discharged from Frankston Hospital on 1 November 20…

emergency medicineintensive carecommunicationsystem
SAcommunity2024-08-29

Coroner's Finding: May, Kunmanara

23y · Female·stab wound of the chest

Kunmanara May, aged 23, was killed by her partner SK in a domestic violence homicide in 2015. Multiple agencies—South Australia Police, Families SA, Aboriginal Family Support Service, and Centacare—knew of escalating vio…

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