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QLD2025-09-05

Findings into the death of Faysal Ishak AHMED

30y · Male·Acute pneumonia and multi-organ failure, due to or as a consequence of traumatic…

Faysal Ishak Ahmed, a 30-year-old Sudanese refugee, died from traumatic brain injury sustained in a fall down stairs at Manus Island Regional Processing Centre on 22 December 2016. He collapsed and fell while alone, like…

emergency medicineintensive caredelaymannitol
VICcommunity2025-09-01

Finding into death of Ms FSZ

32y · Female·Compression of the neck

FSZ, a 32-year-old woman, was killed by her intimate partner NLU through compression of the neck (strangulation) on 24 April 2019. This coronial finding identifies multiple systemic failures in family violence response a…

psychiatryemergency medicinediagnosticcommunicationolanzapine
VICcommunity2025-08-27

Finding into death of Conan James Smith

37y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

A 37-year-old man died in a deliberate head-on motor vehicle collision three days after his partner died from metastatic cancer. He was the sole carer for his 7-year-old son with autism and intellectual disability. The c…

psychiatrygeneral practicecommunicationdelaymirtazapine
NSWcommunity2025-08-22

Inquest into the disappearance and suspected death of Habtom Ghilagaber

30y · Male·unknown - no postmortem examination performed

This inquest examined the 1995 disappearance of Habtom Ghilagaber, a 30-year-old Eritrean mathematics PhD student at UNSW who was reported missing on 25 September 1995, having last been seen alive on 5 September 1995. Th…

psychiatrypsychologysystemcommunicationantipsychotic medication
VIChome2025-08-13

Finding into death of Lillian Rose Thomas

21y · Female·Compression of the neck secondary to hanging

Lillian Rose Thomas, 21, died by hanging on 17 November 2021 at her home in Kyabram, Victoria. She had complex mental health conditions including CPTSD, anxiety, depression, OCD, and personality disorder traits, with a h…

psychiatrygeneral practicesystemdelayprazosin
NSWcommunity2025-08-08

Inquest into the death of Stephen Douglas

62y · Male·Multiple sharp force injuries intentionally inflicted by client during home visi…

Stephen James Douglas, a 62-year-old community mental health nurse, was killed on 28 November 2019 by his client Peter Kemball during a home visit. Kemball had chronic schizophrenia and was experiencing psychosis with de…

psychiatrygeneral practicediagnosticsystempaliperidone
TAShome2025-08-05

Coroner's Finding: Iliev, Patricia

57y · Female·starvation due to insufficient food intake

Patricia Iliev, a 57-year-old woman, died from starvation after progressively restricting her food intake over months while immobilised by chronic back pain. She had a gastrointestinal stromal tumour and advanced lung di…

general practicepsychiatrysystemdelayaspirin
VIChome2025-07-30

Finding into death of William Charles Heddergott

50y · Male·plastic bag asphyxia in the setting of ethanol intoxication and blunt force head…

William Heddergott, 50, died from asphyxiation with head injuries while intoxicated, in circumstances suggesting his mother Erica (who pleaded guilty to murder) perpetrated fatal family violence. Clinical lessons include…

psychiatrypsychologycommunicationsystemalcohol
NSWhome2025-07-30

Inquest into the death of Hilary Gordon-Squire

65y · Male·Pneumonia, due to chronic lung disease with atherosclerotic cardiovascular disea…

A 65-year-old man with severe chronic lung disease, COPD, and coronary artery disease died at home. Evidence suggests he deliberately ingested benzodiazepines and possibly other substances in a self-harm attempt. However…

forensic medicinegeneral practicesystemdelaybenzodiazepines
VIChospital2025-07-30

Finding into death of YTR

78y · Female·Complications of prolonged immobility and malnutrition in a woman with retroperi…

A 78-year-old woman with schizophrenia, depression, and undiagnosed retroperitoneal lymphoma died from septic shock complicating severe pressure ulcers, malnutrition, and dehydration. She had been immobile on a couch for…

geriatric medicineintensive caredelaysystemasenapine
VIChome2025-07-28

Finding into death of Heather Ida Simone Calgaret

30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…

Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …

general practiceaddiction medicinemedicationdiagnosticbuprenorphine
VIChome2025-07-24

Finding into death of Jill Hughes

75y · Female·Infective complications of a left hand injury with diabetic ketoacidosis

A 75-year-old woman died from infective complications of a left hand wound sustained in a fall from a ladder in November 2023, complicated by undiagnosed diabetic ketoacidosis. Despite family encouragement to seek medica…

infectious diseasesendocrinologydelaydiagnostic
NSWcustodial setting (correctional facility) with death at hospital2025-07-23

Inquest into the death of James Cunneen

60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…

James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…

general practiceinfectious diseasesdiagnosticmedicationpantoprazole
NSWcommunity2025-07-10

Inquest into the death of Nathan Markl

31y · Male·Drowning

Nathan Markl, a 31-year-old man with a history of mental illness, intellectual impairment, and substance use disorder, died by drowning in Narrabri Creek on 7 July 2021. He was intoxicated and under the influence of meth…

psychiatryaddiction medicinesystemdelaymethamphetamine
WA2025-07-08

Inquest into the Death of Tim Alan LOOKER

29y · Male·ligature compression of the neck (hanging)

Tim Looker, aged 29, died by suicide in Bunbury Regional Prison on 3 October 2023 by hanging from a bedsheet attached to a protruding bolt in his cell. Tim had ADHD diagnosed since childhood (previously prescribed dexamp…

general practicepsychiatrysystemcommunicationdextroamphetamine
NTcommunity2025-07-07

Inquest into the death of Kumanjayi Walker

19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …

Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…

emergency medicinegeneral practicediagnosticprocedural
TAS2025-07-04

Coroner's Finding: de-identified CF

24y · Male·blunt trauma and drowning due to intentional jumping from Tasman Bridge

A 24-year-old male international student and graduate employee experienced his first acute psychotic episode in December 2022, triggered by workplace stress and unsubstantiated beliefs about colleague manipulation. Initi…

psychiatryemergency medicinedelaycommunicationolanzapine
TAScommunity2025-06-30

Coroner's Finding: de-identified XA

41y · Male·head and chest injuries from fall from height

A 41-year-old man with schizophrenia died by suicide, jumping from the Tasman Bridge on Christmas Eve 2022. He had a 15-year history of mental illness with multiple suicide attempts, previously managed with antipsychotic…

psychiatrygeneral practicesystemdelaypaliperidone
TASaged care2025-06-16

Coroner's Finding: McDonald, Maureen June

87y · Female·Terminal exacerbation of chronic obstructive pulmonary disease; antecedent cause…

Maureen 'Kitty' McDonald, 87, died from terminal exacerbation of COPD with an antecedent sacral pressure wound infection. She was admitted to residential aged care in October 2020 with a stage-two sacral pressure injury …

geriatric medicinegeneral practicesystemcommunicationantibiotics
SAhospital2025-06-11

Coroner's Finding: OHalloran, Emma Louise

48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam

A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…

cardiologygeneral practicesystemcommunicationflecainide

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