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VICcommunity2023-09-13

Finding into death of Joshua Tovey

29y · Male·Stab wound to the chest

Joshua Tovey, aged 29, was fatally stabbed by his brother Jesse on 18 January 2021 following a dispute over repaid money. Jesse was subject to a Community Corrections Order (CCO) for family violence offences at the time.…

systemdelaymethamphetamine
NSWhome2023-09-08

Inquest into the death of BW

31y · Male·hanging

B W, aged 31, died by hanging following emergency police removal of his daughter from his care under the Care and Protection Act. The removal occurred in early hours of 17 April 2020 during COVID-19 lockdown. B W had lon…

paediatricspsychiatrycommunicationsystemalcohol
NSWcommunity2023-09-05

Inquest into the death of Daniel Bolton

30y · Male·Gunshot wound to the neck and head

Daniel Bolton, aged 30, died from a self-inflicted gunshot wound to the neck and head while attempting to avoid arrest by police. He had a history of drug addiction, mental health issues including depression, anxiety and…

psychiatrygeneral practicesystemcommunicationcannabis
TAScommunity2023-08-31

Coroner's Finding: Douglas, Jethro Wolf

24y · Male·Multiple blunt traumatic injuries sustained in single motor vehicle crash

Jethro Wolf Douglas, aged 24, died from multiple blunt traumatic injuries sustained when he drove his vehicle at 101 km/h (twice the posted 50 km/h limit) around a curve he could not negotiate, resulting in a crash. His …

forensic medicinepublic healthsystemdelayalcohol
QLD2023-08-31

DODUNSKI, Gareth Leo

21y · Male·Gross cerebral trauma due to multiple comminuted depressed fractures of skull du…

Gareth Dodunski, a 21-year-old floorhand, was fatally struck by an ST-80 Iron Roughneck tool on 23 June 2013 while setting a dog collar on a drill string. The driller, Jacob Kilby, activated the ST-80 in a moment of inad…

occupational and environmental healthdiagnosticsystem
WAhospital2023-08-30

Inquest into the Death of Kevin George HOWLETT

83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)

An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …

vascular surgerygeneral medicinediagnosticcommunication
SAhospital2023-08-30

Coroner's Finding: Fergusson, Logan Scott

0y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease

Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Chil…

cardiologypaediatricsdelaydiagnosticheparin
VIC2023-08-30

Finding into death of Baby A

0y · Female·Sudden infant death syndrome (SIDS) category 2

Baby A, born on 6 August 2018 to a mother in remand custody at Dame Phyllis Frost Centre, died of SIDS category 2 on 18 August 2018 aged 12 days. She was born with neonatal abstinence syndrome due to maternal methadone u…

neonatologypaediatricssystemcommunicationmethadone
NSWcommunity2023-08-25

Inquest into the death of SG

15y · Male·Hanging

A 15-year-old Aboriginal boy with complex trauma history, including physical abuse, parental mental illness, and 40+ child protection reports, disclosed a suicide attempt to his school counsellor in December 2019. A mand…

psychiatrypaediatricscommunicationsystem
WA2023-08-23

Inquest into the Deaths of Adell Sherylee PARTRIDGE and Veronica Philomena LOCKYER

Female·unascertained

Two Indigenous women from the Pilbara disappeared in late 1998 without trace: Veronica Lockyer (33 years old) and her infant daughter Adell Partridge (7 months old). Veronica was last seen at a Centrelink office in South…

communicationsystem
NSWhome2023-08-22

Inquest into the death of George Campbell

17y · Male·hydrocarbon toxicity (petrol inhalation)

George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …

paediatricspsychiatrycommunicationsystempetrol
WA2023-08-21

Inquest into the Death of Jomen BLANKET

30y · Male·ligature compression of the neck (hanging)

Jomen Blanket, a 30-year-old Aboriginal and Torres Strait Islander man, died by suicide in prison on 12 June 2019 after eight months incarcerated for assault. He had a known suicide plan (hanging from his cell door using…

psychiatrycorrectional healthcommunicationsystem
NSWhospital2023-08-21

Inquest into the death of Maureen Smith

75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis

A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…

orthopaedic surgeryemergency medicinediagnosticcommunicationcorticosteroid injections
TAShome2023-08-18

Coroner's Finding: Lukacevich, Anton

64y · Male·coronary atherosclerosis with early myocardial infarction

A 64-year-old man suffered acute myocardial infarction at home. His wife called triple-0 at 10:34 am reporting classic cardiac symptoms: sudden sweating, shortness of breath, and shoulder pain. The emergency dispatch sys…

cardiologyemergency medicinesystemcommunication
VICcommunity2023-08-18

Finding into death of Jackson David Eales

27y · Male·Injuries sustained in motor vehicle collision (driver)

Jackson Eales, 27, died in a motor vehicle collision at an intersection when truck driver Gerard Voss failed to stop at a stop sign in December 2016. The coroner found it highly probable Voss had undiagnosed severe obstr…

general practicecardiologysystemdelay
NSW2023-08-15

Inquest into the death of Matthew Grieve

27y · Male·Neck compression due to self-inflicted hanging

Matthew Grieve, a 27-year-old first-time inmate with anxiety, depression and panic disorder, died by self-inflicted hanging in custody after eight days without prescribed medication. Critical failures included: an unsign…

psychiatrygeneral practicedocumentationcommunicationquetiapine
NSWhome2023-08-15

Inquest into the death of LA

5y · Female·Hypoxic-ischaemic Encephalopathy due to methadone toxicity

LA, a five-year-old girl, died from hypoxic-ischaemic encephalopathy due to methadone toxicity on 22 January 2017. She ingested methadone at her grandfather's home while staying overnight; the grandfather was enrolled in…

paediatricsintensive caredelaycommunicationmethadone
TAShome2023-08-11

Coroner's Finding: Dobson, Barbara Maree

45y · Female·mixed drug toxicity including heroin and methylamphetamine

Barbara Dobson, a 45-year-old woman with a long history of substance abuse, violent relationships, and mental health issues, died of mixed drug toxicity including heroin and methylamphetamine on 24 February 2020. Police …

emergency medicineforensic medicinedelaysystemheroin
NSWhospital2023-08-11

Inquest into the death of Andrew Stubbs

32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome

Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…

general practicepsychiatrydiagnosticmedicationlithium
NSWcommunity2023-08-08

Inquest into the death of Simon Miles

42y · Male·heroin and methylamphetamine toxicity

Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing…

addiction medicinepsychiatrysystemcommunicationheroin

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