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SA2023-05-12

Coroner's Finding: Morrison, Wayne Fella

29y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to out of hospital …

Wayne Fella Morrison, a 29-year-old Aboriginal man with undiagnosed coronary artery disease (70% stenosis of right coronary artery), died following cardiac arrest during his detention at Yatala Labour Prison. After attac…

emergency medicineintensive caresystemdelay
NSWhospital2023-05-09

Inquest into the death of Harriet Ostler

1y · Female·sudden cardiac death on a background of rhinovirus infection

Harriet Ostler, a 19-month-old toddler, was admitted to Port Macquarie Base Hospital with viral respiratory symptoms and died from sudden cardiac death due to underlying myocarditis/cardiomyopathy precipitated by rhinovi…

paediatricsemergency medicinediagnosticcommunicationsalbutamol
TAShospital2023-05-05

Coroner's Finding: Pedler, Anne Helen

71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis

71-year-old woman presented to ED with signs of circulatory failure (hypotension, tachycardia, tachypnoea, hypoxia) and progressive leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pulmonary emb…

emergency medicinecardiologydiagnosticdelaycannabis oil
TAShome2023-05-04

Coroner's Finding: Chuah Soo Lan

65y · Female·undetermined; possibly ischaemic heart disease or squamous cell carcinoma of ton…

A 65-year-old Malaysian woman with advanced squamous cell carcinoma of the tongue refused medical treatment due to visa concerns and preference for alternative therapy. She deteriorated over months with worsening oral sy…

oncologydentistrydelaysystem
QLD2023-05-02

Watts, Billy-Joh

36y · Male·Multiple injuries due to struck by falling pipe

Billy-Joh Watts, a 36-year-old truck driver, was fatally struck by a falling steel pipe while acting as a spotter during unloading operations. Multiple contributing factors were identified: he had worked 26 days consecut…

occupational and environmental healthpsychologysystemcommunication
VICmental health2023-05-02

Finding into death of Duncan Stuart Sparke

48y · Male·Hanging

Duncan Sparke, a 48-year-old man with a history of suicidal ideation and depression, absconded from a locked psychiatric unit at The Alfred Hospital on 24 April 2017 while subject to a Temporary Treatment Order. He was r…

psychiatryemergency medicinesystemdelayfluoxetine
VICcommunity2023-05-02

Finding into death of Trevor Henry McKie

48y · Male·Coronary artery atherosclerosis in the setting of immersion

Trevor McKie, 48, an experienced mariner, died from coronary artery atherosclerosis while attempting to transfer between boats during deteriorating weather on Lake Wellington. He fell overboard in rough conditions (seas …

delaymirtazapine
VIChospital2023-05-02

Finding into death of Mr C

56y · Male·Complications of clostridium difficile and malnutrition in the setting of cerebr…

Mr C was a 56-year-old man with cerebral palsy and acquired brain injury who died from complications of Clostridioides difficile infection and malnutrition. He was admitted to hospital on 21 January 2022 with diarrhoea, …

general medicinegastroenterologydelayvancomycin
NSWhome2023-04-26

Inquest into the death of AX

70y · Female·Cause of death could not be determined - available evidence does not allow a fin…

A 70-year-old woman died unexpectedly at home in August 2017. Initially certified as hypertensive heart disease without autopsy, the death was later investigated as a potential homicide following allegations by her forme…

forensic medicinecardiologysystemdelaycandesartan
TAShome2023-04-20

Coroner's Finding: Young, Luke Trevor

42y · Male·mixed prescription drug toxicity (sertraline, amlodipine, lamotrigine, quetiapin…

Luke Trevor Young, 42, died from mixed prescription drug toxicity (sertraline, amlodipine, lamotrigine, quetiapine) in a suicide by overdose. He had severe, longstanding bipolar II disorder with chronic suicidality, comp…

psychiatrygeneral practicesystemdelaysertraline
VICmental health2023-04-20

Finding into death of Craig Harvey

50y · Male·Hanging

Craig Harvey, a 50-year-old man with depression, polysubstance use disorder, and antisocial personality disorder, died by hanging in Casey Hospital's mental health inpatient ward while on a compulsory admission. He was a…

psychiatrysystemdelaydiazepam
VICcommunity2023-04-19

Finding into death of J L

15y · Female·Hanging

A 15-year-old girl with major depressive disorder and bulimia nervosa died by suicide in June 2019. She had received treatment from a private psychologist from 2017-2018 within the constraints of a GP Mental Health Care …

psychologygeneral practicecommunicationsystem
VIChospital2023-04-18

Finding into death of Abdullahi Osman Bashir

27y · Male·Head injury

Abdullahi Bashir, 27, died from a severe head injury sustained during an alleged altercation on 7 June 2017. Following a punch to the face, he fell backwards and struck his head on the road. He was taken to a private res…

neurosurgeryintensive carediagnosticdelaymethamphetamine
NSWcommunity2023-04-18

Inquest into the death of Gordon Copeland

22y · Male·presumed drowning

Gordon Copeland, a 22-year-old Gomeroi man, drowned in the Gwydir River after fleeing police during a vehicle check. A critical failure occurred in the initial police search: officers heard him in the water around 2:45am…

diagnosticcommunication
WAhospital2023-04-17

Inquest into the Death of Edward Ivan AFRICH

64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …

Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…

respiratory medicinecardiologycommunicationsystemthiamine
VIChome2023-04-14

Finding into death of Jonathan Travis Palmer

36y · Male·Bronchopneumonia in a man with epilepsy

Jonathan Palmer, a 36-year-old man with epilepsy and intellectual disability living in a group home, died from bronchopneumonia on 24 February 2018. On 23 February, he developed respiratory symptoms (coughing, runny nose…

neurologygeneral practicecommunicationsystemlamotrigine
NSWhome2023-04-14

Inquest into the death of Stanley Leonard RUSSELL

45y · Male·gunshot wound to the chest with associated significant blood loss

Stanley Russell, a 45-year-old Aboriginal man with mild intellectual disability, was shot dead by NSW police executing a bench warrant at his home on 9 November 2021. He had suffered childhood sexual abuse, his brother d…

forensic medicineemergency medicinediagnosticcommunicationmethamphetamine
SA2023-04-06

Coroner's Finding: Chilcott, Zhane Andrew Keith

13y · Male·Hanging

Zhane Chilcott, age 13, died by suicide at a residential care facility after 12 years in state care with 18 placements. The coroner found multiple systemic failures: inadequate scrutiny of his first placement with LB des…

paediatricsgeneral practicesystemcommunication
QLDcommunity2023-04-05

Grimes, William George

31y · Male·Burns

31-year-old George Grimes with longstanding schizophrenia was found threatening self-immolation after consuming alcohol and missing antipsychotic medication. Despite police de-escalation attempts, he doused himself with …

psychiatryemergency medicinediagnosticcommunicationquetiapine
TAShome2023-04-03

Coroner's Finding: De-identified HJ

71y · Female·starvation

A 71-year-old woman with chronic mental illness died of starvation in her home in Tasmania. Police attended on 9 December 2021 for a welfare check and found her severely malnourished, mentally unwell, and unable to care …

psychiatrygeneral practicecommunicationsystem

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