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QLD2023-10-03

Findings of the inquest into the death of GLT

46y · Male·Methylamphetamine toxicity and coronary atherosclerosis

A 46-year-old man died in police custody following a domestic violence order breach arrest in Rockhampton, Queensland. The death resulted from a combination of methylamphetamine toxicity, significant coronary artery dise…

emergency medicineintensive carediagnosticdelaymethamphetamine
VICcommunity2023-09-18

Finding into death of Meeram Bano

2y · Female·Hypoxic ischaemic encephalopathy in the setting of immersion

Meeram Bano, aged 2 years, died from hypoxic ischaemic encephalopathy following immersion in a pond at Footscray Park on 27 December 2021. She was declared dead on 30 December 2021. While under adult supervision at a fam…

intensive careemergency medicinesystemdelaymidazolam
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
TAS2023-07-05

Coroner's Finding: Crump, Damian Michael

36y · Male·Mixed prescription drug toxicity (morphine, lignocaine, amiodarone and midazolam…

Damian Crump, aged 36, was an intensive care paramedic with Ambulance Tasmania who died by suicide on 23 December 2016 by deliberately consuming fatal quantities of morphine, lignocaine, amiodarone and midazolam stolen f…

paramedicinepsychiatrysystemdelaymorphine
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
VIChospital2023-02-24

Finding into death of Justin Patrick Crome

39y · Male·Injuries sustained in a fall from the Camberwell train station bridge

Justin Crome, a 39-year-old man with delusional disorder and schizophrenia, died by suicide after jumping from a railway bridge on 13 February 2020. He had a history of mental illness since 2016, multiple psychiatric adm…

psychiatryemergency medicinecommunicationdelaypaliperidone
SAhome2022-12-16

Coroner's Finding: Reid, Paul

50y · Male·ischaemic heart disease

Paul Reid, a 50-year-old Aboriginal man with severe ischaemic heart disease and poor medication compliance, died of a cardiac arrhythmia during his arrest by South Australian Police. He was highly intoxicated (BAC 0.25%)…

cardiologyforensic medicinediagnosticsystemalcohol
TAShospital2022-11-16

Coroner's Finding: Phillips, William Garnett

82y · Male·bronchopneumonia

William Garnet Phillips, an 82-year-old widower with cardiac history, died from bronchopneumonia while frail and underweight (58 kg). He lived alone, was socially isolated, and refused all offers of assistance from famil…

general practiceemergency medicinedelay
VIChome2022-10-04

Finding into death of Baby R

3y · Unknown·Unascertained - natural causes; evidence of aspiration pneumonia, hypoxic-ischae…

Baby R, born at 38 weeks gestation to a mother with previous pregnancy losses, was small-for-gestational-age (SGA, 10th centile). The mother was appropriately excluded from the hospital-supported home birth program due t…

obstetricsmidwiferysystemcommunication
VIChospital2022-09-27

Finding into death of Neville Ernest Mills

66y · Male·Ruptured abdominal aortic aneurysm

A 66-year-old man presented to the Emergency Department with left-sided abdominal pain on 14 July 2021. After waiting over 6 hours in a crowded ED with restricted access to treatment spaces, he left without medical asses…

emergency medicinegeneral surgerysystemdelayibuprofen
NSWhospital2022-09-26

Inquest into the death of Faithe Baxter

22y · Female·cardiac arrest of uncertain cause noting the existence of drug toxicity; the dru…

Faithe Baxter, aged 22, died from cardiac arrest due to methamphetamine toxicity after using multiple drugs including methamphetamine, benzodiazepines, opioids and nitrous oxide. She became unconscious in a car overnight…

emergency medicineintensive caredelaymethamphetamine
TAScommunity2022-07-29

Coroner's Finding: Chamberlain, Pamela Jacqueline

55y · Female·asphyxia due to choking on food (steak)

A 55-year-old woman with multiple comorbidities including morbid obesity, schizophrenia, depression, and substance use disorder died from asphyxia caused by choking on food while at a friend's home in supported accommoda…

emergency medicinepsychiatrysystemcommunicationdiazepam
WAprison2022-07-22

Inquest into the Death of Callum MITCHELL

26y · Male·ligature compression of the neck (hanging)

Callum Mitchell, aged 26, died by ligature compression of the neck (hanging) in his cell at Hakea Prison on 21 April 2019. He had a longstanding history of self-harm, severe personality disorders (borderline and antisoci…

psychiatrycorrectional healthsystemcommunicationtramadol
TAShome2022-07-15

Coroner's Finding: Summers, Nicholas John

41y · Male·heart failure related to exsanguination due to traumatic rupture of an arteriove…

Nicholas Summers, a 41-year-old kidney transplant recipient, died from traumatic rupture of an arteriovenous fistula with massive hemorrhage on 16 February 2016. He had returned to Tasmania under nephrologist Dr Mathew's…

nephrologyvascular surgerysystemdelay
TAScommunity2022-07-04

Coroner's Finding: Leighton, Garth Mcdonald

58y · Male·chest and abdominal injuries sustained in motor vehicle collision

A 58-year-old experienced motorcycle rider died from massive chest and abdominal injuries after losing control on a rural curve and colliding with an oncoming vehicle. He was initially conscious with three doctors presen…

emergency medicinesurgerysystemdelay
QLDcommunity2022-06-29

Clarke, Hannah Ashlie; Baxter, Aaliyah Anne; Baxter, Laianah Grace; Baxter, Trey Rowan Charles; Baxter, Rowan Charles

Mixed·Hannah Clarke: multi-organ failure due to effects of fire; Aaliyah, Laianah and …

Hannah Clarke, aged 33, and her three children (ages 6, 4, and 3) were killed by her estranged husband Rowan Baxter on 19 February 2020 in Camp Hill, Queensland. Baxter forced his way into Hannah's car, doused the family…

emergency medicineparamedicinediagnosticcommunication
WA2022-06-17

Inquest into the 4 Deaths at Mount Augustus

heat stroke (environmental exposure) / hyperthermia; Mr Buske: atherosclerotic h…

Four deaths occurred on Mount Augustus summit trail in 2019-2020 during hot weather conditions. All deceased experienced heat stroke with dehydration as the primary mechanism of death. The coroner identified inadequate p…

emergency medicineforensic medicinesystemcommunication
VIC2022-05-16

Finding into death of Marcus Lloyd Adams

44y · Male·Stab wound to the chest

Marcus Lloyd Adams, a 44-year-old man, died from a stab wound to the chest inflicted by his de facto partner during a physical altercation at a caravan park on 20 September 2019. There was no prior history of family viol…

forensic medicineemergency medicinedelaymethamphetamine
VIC2022-03-10

Finding into death of Joanne Callahan

43y · Female·choking on a food bolus

Joanne Callahan, a 43-year-old woman with intellectual disability and autism, died from choking on a food bolus while attending a disability day program. Critical failures in communication between her residential care pr…

speech pathologyparamedicinecommunicationsystem
VIChospital2022-02-22

Finding into death of Matthew Lee Dongelmans

30y · Male·Complications of methylamphetamine toxicity

Matthew Dongelmans, aged 30, died from complications of methylamphetamine toxicity after being arrested for breaching a family violence intervention order. He consumed methylamphetamine prior to arrest, likely in panic w…

emergency medicineintensive caredelaysystemmethamphetamine

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