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VIC2024-06-19

Finding into death of X Y

17y · Female·Neck compression by hanging (suicide)

XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as …

paediatricspsychiatrycommunicationsystemvenlafaxine
VIChospital2024-06-14

Finding into death of Joshua Paul Coates

49y · Male·Acute myocardial infarction complicating prosthetic valve thrombosis in a man wi…

Joshua Paul Coates, aged 49, died from acute myocardial infarction complicating prosthetic valve thrombosis following mechanical aortic valve replacement. Post-mortem examination revealed a large blood clot obstructing h…

cardiothoracic surgerycardiologycommunicationsystemwarfarin
NSWcommunityPodcast2024-06-14

Inquest into the death of Ada Holland

90y · Female·fatal injuries from sustained attack by three dogs

Ada Holland, aged 90, was fatally attacked by three dogs on Collingwood Beach on 29 March 2020. One week prior, the same dogs escaped their owner's premises and attacked another person. Council rangers attended but faile…

systemdelay
WAprison2024-06-12

Inquest into the Death of Alf Deon EADES

46y · Male·head injury complicated by bronchopneumonia, with palliation

A 46-year-old remand prisoner died from traumatic brain injury sustained during a severe prison assault. Critical failures in responding to cell call alarms preceded the attack. Prison officers answered multiple distress…

correctional healthneurosurgerycommunicationsystem
NT2024-06-12

Inquest into the death of Mr Dooley

37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia

Glen Dooley, a 37-year-old Aboriginal man, died of atherosclerotic heart disease and dyslipidaemia while in custody at Darwin Correctional Centre. His death was avoidable. He had abnormal ECGs in 2019 and 2022 that were …

cardiologygeneral practicediagnosticcommunicationatorvastatin
VIChome2024-06-11

Finding into death of Martin Page

39y · Male·most likely suicide; possibly accidental death from untreated epilepsy or natura…

Martin Page, a 39-year-old man with epilepsy, schizophrenia or Asperger's syndrome, severe obsessive-compulsive behaviours, and intellectual disability, disappeared from his family home in October 2006 and has not been l…

psychiatryneurologysystemdelay
VIChospital2024-06-04

Finding into death of Stephen John Lunson

68y · Male·Pneumonia on a background of interstitial lung disease

Stephen Lunson, a 68-year-old man with intellectual disability, epilepsy, and interstitial lung disease, died from pneumonia. He had been under medical review for progressive respiratory symptoms since 2019. In early Dec…

respiratory medicinegeneral practicedelayprednisolone
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
WAhome2024-05-28

Inquest into the Death of Cameron Anthony FYFE

27y · Male·gunshot injury to the head

A 27-year-old Western Australian police officer with a longstanding history of depression and anxiety took his own life using his police-issued firearm stored at home. He had struggled with mental health since 2017, atte…

occupational and environmental healthpsychiatrysystemcommunicationdesvenlafaxine
WAhospital2024-05-23

Inquest into the Death of Baby BE (Name Subject to Suppression Order)

0y · Female·brain death complicating head and neck injury

A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult on at least two occasions: once around 6 May 2019 (evidenced b…

paediatricsneonatologydiagnosticcommunicationmethamphetamine
SAhospital2024-05-22

Coroner's Finding: Kolega, Sime

54y · Male·multi-organ failure and sepsis complicating fulminant pneumonia with empyema (op…

A 54-year-old man died from sepsis and multi-organ failure secondary to fulminant pneumonia with empyema. He presented to his GP on 1 April 2021 with concerning signs including bilateral oedema, fever, and respiratory sy…

general practiceemergency medicinedelaysystemflixotide
NSW2024-05-21

Inquest into the death of Mohamed Warwar

35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…

35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues an…

psychiatrycardiologycommunicationdiagnosticamisulpride
QLDcommunity2024-05-20

PHILLIPS, Sharron

20y · Female·Undetermined

This coronial finding concerns the 1986 disappearance and suspected murder of 20-year-old Sharron Phillips. No medical or clinical issues are central to this case. The inquest examined evidence that Raymond Mulvihill, a …

systemdelay
NSW2024-05-17

Inquest into the death of Vicki Higgins

48y · Female·Ischaemic bowel; coronary artery disease, diabetes mellitus and Crohn's disease …

Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (with prior colectomy and ileostomy), and coronary artery disease, died from ischaemic bowel on day 17 of incarceration at Junee Correctional Centre du…

general practicegastroenterologydiagnosticcommunicationinsulin
NSW2024-05-17

Inquest into the death of Vicki Higgins

48y · Female·Ischaemic bowel, with contributing conditions of coronary artery disease, diabet…

Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (requiring ileostomy), and coronary artery disease, died from ischaemic bowel while in custody at Junee Correctional Centre on 29 January 2022, only 17…

general practicegastroenterologydiagnosticdelay
SAhospital2024-05-16

Coroner's Finding: Fisher, Lynne Patricia

60y · Female·sepsis due to community acquired pneumonia

Lynne Patricia Fisher, 60, presented to Mount Barker Hospital ED on 26 September 2018 with bilateral community-acquired pneumonia and was discharged after 6.5 hours despite clinical deterioration. She collapsed at home w…

emergency medicinegeneral practicediagnosticdelayamoxicillin/clavulanate
NSWmental health2024-05-16

Inquest into the death of Roger Frederick Schnelle

59y · Male·head injuries

Roger Schnelle, a 59-year-old accountant, died from head injuries sustained through intentional self-harm while involuntarily detained at Nolan House mental health facility in April 2021. He developed sudden onset severe…

psychiatrygeneral practicediagnosticcommunicationsertraline
VICcommunity2024-05-15

Finding into death of Denise Lucina Roberts

63y · Female·Combined features of bronchopneumonia, emphysema and ischaemic heart disease on …

A 63-year-old woman with depression, anxiety, liver cirrhosis, and chronic drug use died from bronchopneumonia, emphysema, and ischaemic heart disease following a prolonged lie on the ground with hypothermia. She missed …

general practiceaddiction medicinecommunicationsystemdiazepam
VIChome2024-05-14

Finding into death of PJQ PJQ

18y · Female·Multidrug toxicity (GHB, amphetamines, benzodiazepines)

PJQ was an 18-year-old in state care who died from multidrug toxicity (GHB, amphetamines, benzodiazepines) after being discharged early from a residential rehabilitation program. She had complex trauma history, PTSD, and…

paediatricspsychiatrysystemdelayGHB
VIC2024-05-14

Finding into death of Brian Richard Pope

40y · Male·compression of the neck due to hanging

Brian Pope, a 40-year-old man with longstanding mental health issues including major depressive disorder, anxiety, learning disability (dyslexia), and substance abuse history, died by suicide in prison 20 days after rema…

psychiatrycorrectional healthcommunicationsystemmirtazapine

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