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QLDhospital2025-03-31

Inquest into the death of Jamie Brian Campbell

43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…

A 43-year-old man with methamphetamine toxicity was restrained by police and given two doses of droperidol by paramedics who failed to recognize he was critically unwell. The first dose was clinically indicated, but the …

emergency medicinetoxicologydiagnosticmedicationmethamphetamine
TAShospital2025-03-17

Coroner's Finding: Phillips, Helen Lynette

77y · Female·intracranial haemorrhage (subdural, intraventricular and brainstem)

A 77-year-old woman fell from a ladder on 12 December 2022, suffering loss of consciousness and rib fractures. No brain CT scan was performed at Mersey Community Hospital despite the mechanism of injury and unconsciousne…

emergency medicinecardiologydiagnosticdelaythrombolytic agents
NSWcommunity2025-03-06

Inquest into the death of Fiona Turnbull

59y · Female·multiple injuries from fall from height

Fiona Turnbull, a 59-year-old woman with chronic schizophrenia on clozapine, died from multiple injuries after falling from her third-floor balcony on 12 October 2017 during a psychotic relapse. The death occurred shortl…

psychiatryemergency medicinedelaycommunicationclozapine
VIChome2025-02-26

Finding into death of Jonathan Alan Uphill

84y · Male·Ischaemic heart disease and coronary artery atherosclerosis in the setting of ty…

Jonathan Uphill, an 84-year-old man with extensive comorbidities including type 2 diabetes, hypertension, and prior cardiac risk factors, died of ischaemic heart disease with coronary artery atherosclerosis. He underwent…

oral and maxillofacial surgeryanaesthesiadelaycodeine
VIChome2025-02-14

Finding into death of Martin Barlow

67y · Male·Head injuries sustained in falls

Martin Barlow, 67, died from head injuries sustained in two falls on 5 August 2022 while intoxicated (BAC 0.17 g/100mL). He suffered subarachnoid haemorrhage and subdural haemorrhage. After Ms Burrell called emergency se…

emergency medicineparamedicinedelaysystemalcohol
VIChome2024-12-12

Finding into death of L G

16y · Male·Complications of acute alcohol intoxication

A 16-year-old male died from complications of acute alcohol intoxication after consuming a dangerous quantity of alcohol (estimated blood alcohol content 0.34-0.4 g/100mL at midnight) at a family Christmas gathering. He …

emergency medicinetoxicologydelaysystemalcohol
NSWhome2024-11-28

Inquest into the death of Michael Peachey

27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…

Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…

emergency medicinepsychiatryproceduralcommunicationdroperidol
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
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
TAShome2024-08-09

Coroner's Finding: Mansell-Moore, Codie

17y · Male·epileptic seizure complicating idiopathic epilepsy

17-year-old Codie Mansell-Moore died from epileptic seizures on 10 December 2018. An ambulance was called at 6:09am while he was seizing, but paramedics staged around the corner and did not enter his home for 48 minutes …

emergency medicineparamedicinecommunicationsystemlevetiracetam
WAhome2024-07-31

Inquest into the Death of Joseph Charles ABELA

34y · Male·Gunshot injuries to chest and left shoulder

Joseph Abela, a 34-year-old with chronic paranoid schizophrenia and polysubstance use, died from gunshot wounds inflicted by police during a mental health welfare check on 25 October 2021. Critical clinical failures prec…

psychiatrycorrectional healthdiagnosticsystemhaloperidol
NT2024-05-30

Inquest into the death of Douglass Maggie

46y · Male·Complications arising from hyperthermia, with alcohol intoxication and underlyin…

A 46-year-old man with epilepsy, hypertension, and COPD died after prolonged exposure to heat in a locked vehicle on a hot day in Darwin. He had been drinking heavily and was left sleeping in the car while companions vis…

emergency medicineparamedicinesystemdelayalcohol
NSWcommunity2024-05-03

Inquest into the death of Keith Titmuss

20y · Male·exertional heat stroke

A 20-year-old professional rugby league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest aerobic fitness of hi…

sports medicineemergency medicinesystemdelaymidazolam
VIChome2024-04-23

Finding into death of Robert Norman Spencer

59y · Male·ischaemic heart disease in the setting of chronic ethanol use

Robert Spencer, 59, called 000 at 4:27 am reporting weakness and inability to mobilise following a fall. He was triaged as Code 3 (non-urgent) and underwent secondary triage call-back attempts without success. An ambulan…

emergency medicineparamedicinesystemdelay
NSWcommunity2024-02-19

Inquest into the death of Omar Mohammad

33y · Male·Irreversible hypoxic brain injury secondary to acute cocaine toxicity

Omar Mohammad, a 33-year-old man with recent mental health concerns and drug use, ingested a small plastic bag containing cocaine whilst being arrested for trespass on 10 August 2020. He died 44 days later from irreversi…

emergency medicinetoxicologycommunicationdelaycocaine
VICcommunity2024-01-15

Finding into death of Michael John O'connell

57y · Male·Pneumonia

Michael John O'Connell, a 57-year-old man with Down's syndrome and Alzheimer's disease-related cognitive decline, died from pneumonia while resident in specialist disability accommodation. On 26 April 2023, he exhibited …

general practicedisability medicinedelaymirtazapine
VIChospital2023-12-13

Finding into death of RW C

43y · Male·exsanguination from incised wounds to the arms - self inflicted

A 43-year-old man with schizophrenia, PTSD, and methamphetamine use died from exsanguination following self-inflicted incised wounds to both arms. He had been discharged from psychiatric inpatient care on 1 February 2020…

psychiatryemergency medicinecommunicationdelayrisperidone
WAhospital2023-12-13

Inquest into the Death of Ashleigh Rebecca HUNTER

26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia

Ashleigh Rebecca Hunter, a previously healthy 26-year-old, died from meningococcal septicaemia (W strain) within 3 hours of arriving at Royal Perth Hospital. She presented with severe generalised pain (10/10), tachycardi…

emergency medicineinfectious diseasesdiagnosticsystemMDMA
NSWcommunity2023-11-30

Inquest into the death of Jacob Carr

53y · Male·Gunshot wound to the left thigh with transection of femoral artery and vein; exs…

Jacob Carr died from a gunshot wound to his left thigh sustained during a police operation at his home. He had assaulted his elderly mother, and police responded to a domestic violence call. During confrontation, Mr Carr…

emergency medicineparamedicinesystemdelayalcohol
SAcommunity2023-10-13

Coroner's Finding: Adams, Michael Gerard

62y · Male·cardiac arrest complicating psychotic episode

Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applie…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine

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