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SAaged care2026-02-12

Coroner's Finding: D Angelo, Adelina

88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…

An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatra…

general practicegeriatric medicinediagnosticcommunicationfurosemide
NSWmental health2026-02-05

Inquest into the deaths at Westfield Bondi Junction Executive Summary

41y · Male·Gunshot wounds to neck and chest (perpetrator Joel Cauchi); stab wounds (six vic…

On 13 April 2024, Joel Cauchi stabbed 16 people at Westfield Bondi Junction, NSW, fatally wounding six: Dawn Singleton, Jade Young, Yixuan Cheng, Ashlee Good, Faraz Tahir, and Pikria Darchia. Cauchi was shot and killed b…

psychiatrygeneral practicediagnosticcommunicationclozapine
VIChome2026-02-03

Finding into death of Jeffrey Thomas Wilson

76y · Male·Effects of fire due to home oxygen ignition in the setting of smoking; lung canc…

A 76-year-old man with lung cancer and mesothelioma died from thermal injuries sustained when his home oxygen ignited while smoking. He had been discharged on self-funded home oxygen despite a recent smoking history, aft…

respiratory medicinepalliative caresystemdelay
WAhome2026-01-23

Inquest into the Death of Sean Theo WINMAR (Mr STW)

46y · Male·Complications of ligature compression of the neck (hanging)

Sean Theo Winmar, a 46-year-old Aboriginal man, died by suicide on 11 August 2022 while on an interim supervision order after his release from prison. He had depression, substance use disorder, and chronic suicidal ideat…

general practiceaddiction medicinesystemdelaymethamphetamine
VICaged care2026-01-19

Finding into death of Kevin Thomas Maloney

39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…

Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…

psychiatryaddiction medicinecommunicationsystemheroin
QLDaged care2026-01-15

Inquest into the death of Steven Thelander

29y · Male·Ketoacidosis as a consequence of diabetes mellitus (Type 1)

Steven Thelander, aged 29, died from ketoacidosis due to poorly controlled Type 1 diabetes while in residential disability support care at Multicap. He had cerebral palsy with severe intellectual impairment and epilepsy …

general practiceendocrinologydiagnosticcommunicationinsulin
NSWhospital2026-01-13

Inquest into the death of Paul Harris

43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…

Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …

general practiceemergency medicinediagnosticcommunicationceftriaxone
WA2026-01-08

Inquest into the Death of Lewis Walter WARD

Male·out-of-hospital cardiac arrest due to atherosclerotic cardiovascular disease and…

Lewis Walter Ward, a Ngarinyin man in his early thirties, died from out-of-hospital cardiac arrest while playing sport at West Kimberley Regional Prison. He had Type 2 diabetes, hypertension, dyslipidaemia, and was a smo…

cardiologyemergency medicinediagnosticsystem
NSWhospital2025-12-19

Inquest into the death of JBO

27y · Female·Cardiac arrhythmia (first confirmed as ventricular fibrillation) of unascertaine…

A 27-year-old Aboriginal woman suffered sudden cardiac arrhythmia (ventricular fibrillation) immediately after recording video evidence of a suspected breach of her protective apprehended personal violence order (APVO). …

emergency medicinecardiologycommunicationsystemamiodarone
WA2025-12-17

Inquest into the Death of Child RK (Name Subject to Suppression Order)

14y · Female·ligature compression of the neck (hanging)

Child RK, aged 14, died by suicide while in Department of Communities care at a therapeutic residential group home on 20 April 2022. She had Complex PTSD from childhood trauma and presented multiple times to emergency de…

paediatricsgeneral practicecommunicationsystemmelatonin
NSWhome2025-12-17

Inquest into the death of MQ

55y · Female·acute necrotising bronchopneumonia

MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…

general practiceemergency medicinediagnosticdelay
VIChospital2025-12-08

Finding into death of Graeme William Kenny

61y · Male·Right lower lobe pneumonia

Graeme William Kenny, a 61-year-old man with trisomy 21 and dementia, died from right lower lobe pneumonia on 25 December 2024 at Monash Medical Centre following palliative care. He developed upper respiratory symptoms o…

emergency medicinegeneral practicediagnosticdelayibuprofen
VICcommunity2025-12-04

Finding into death of Mr PNF

60y · Male·Neck compression secondary to hanging

A 60-year-old man with Type 2 diabetes and low mood died by hanging within 24 hours of being interviewed by police regarding child sexual abuse allegations. While police identified that suspects are at heightened suicide…

general practicepsychiatrycommunicationsystemfluoxetine
TAShome2025-12-02

Coroner's Finding: de-identified DQ

54y · Female·mixed drug toxicity (methadone and diazepam)

A 54-year-old woman with long-standing opioid use disorder died from mixed methadone and diazepam toxicity. She had tripled her methadone dose by injecting additional takeaway doses alongside her prescribed pharmacy dose…

general practicepharmacologydiagnosticmedicationmethadone
VIChome2025-11-18

Finding into death of JZA

65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …

A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…

geriatric medicineinfectious diseasessystemcommunicationpholcodine
NSW2025-10-22

Inquest into the Death of Frank Dwayne COLEMAN

43y · Male·methadone toxicity

Frank Coleman, a 43-year-old First Nations man, died of methadone toxicity after being supplied diverted methadone by another inmate while imprisoned at Long Bay Correctional Complex. Mr Coleman had repeatedly requested …

addiction medicinepsychiatrydiagnosticsystemmethadone
QLDhome2025-10-17

Inquest into the death of Alexandria Catherine Forrester

39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…

A 39-year-old woman with opioid dependency died from cardiac arrest caused by methadone toxicity. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatmen…

addiction medicinegeneral practicediagnosticmedicationmethadone
VIChome2025-10-16

Finding into death of Ms YPM

27y · Female·Hanging

Ms YPM, a 27-year-old woman with a long history of borderline personality traits, depression, anxiety and eating disorder, died by hanging on 17 May 2020. In the preceding two weeks, she presented to Alfred Hospital foll…

psychiatryemergency medicinecommunicationdelayagomelatine
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

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