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VICcommunity2022-11-15

Finding into death of Katica Perinovic

42y · Female·Multiple stab wounds

A 42-year-old woman with first episode psychosis was referred to community mental health services in November 2020 after acute onset of paranoid delusions. She was commenced on risperidone but showed poor engagement and …

psychiatrygeneral practicediagnosticcommunicationrisperidone
VIChome2022-11-15

Finding into death of Anna Perinovic

5y · Female·Multiple stab wounds to the back

Anna Perinovic, age 5, died from multiple stab wounds inflicted by her mother Katica during a first episode psychosis. Katica had been referred to NorthWestern Mental Health in November 2020 after developing paranoid tho…

psychiatrygeneral practicediagnosticcommunicationrisperidone
VIChome2022-11-15

Finding into death of Claire Perinovic

7y · Female·Multiple stab wounds to the back

Claire Perinovic, aged 7, died from multiple stab wounds inflicted by her mother Katica during a filicide-suicide incident. Katica had been diagnosed with First Episode Psychosis in November 2020 and treated by NorthWest…

psychiatrygeneral practicecommunicationsystemrisperidone
VIChome2022-11-15

Finding into death of Matthew Perinovic

3y · Male·Multiple stab wounds to the back

Matthew Perinovic, aged 3 years, died from multiple stab wounds inflicted by his mother Katica during a first-episode psychosis. Katica had been receiving mental health treatment from NorthWestern Mental Health Service f…

psychiatrygeneral practicecommunicationsystemrisperidone
TASaged care2022-11-08

Coroner's Finding: Kerr,Anthony Neville

81y · Male·pneumonia due to traumatic internal bleeding of the chest wall sustained in fall…

An 81-year-old man with Parkinson's disease, dementia, and multiple comorbidities residing in aged care suffered an unwitnessed fall on 6 June 2021, sustaining a right-sided chest wall haematoma. Staff found him at 7:40a…

geriatric medicineemergency medicinedelaysystem
TASaged care2022-11-08

Coroner's Finding: Oates, Janet Patricia

83y · Female·Hospital-acquired pneumonia caused by injuries from fall; frailty and osteoporos…

An 83-year-old woman died from hospital-acquired pneumonia following spinal fractures sustained in a fall from a mobility hoist at an aged care facility. The hoist failed when the spreader bar detached due to a worn and …

geriatric medicineneurosurgerysystemdelay
NSW2022-11-08

Inquest into the death of Andrew Gilbertson

42y · Male·methadone toxicity

Andrew Gilbertson, a 42-year-old man with bipolar disorder and substance use disorder, died from methadone toxicity while in custody at Long Bay Correctional Centre. He was not enrolled in opioid substitution therapy but…

forensic medicinepsychiatrysystemdelaymethadone
NSWcommunity2022-11-04

Inquest into the disappearance and suspected death of Morgan Rae

30y · Male·Unable to be ascertained

Morgan Rae, a 30-year-old man with chronic pain and recent life stressors, disappeared on 31 January 2020 from the Bundeena area. The coronal finding examines the NSW Police investigation into his disappearance. Critical…

systemcommunication
NSWhospital2022-10-28

Inquest into death of Dane LOCKWOOD

33y · Male·methylamphetamine toxicity; antecedent causes being the physiological effects of…

A 33-year-old man with methamphetamine addiction and possible schizophrenia attended the ED seeking help while acutely intoxicated, psychotic and sleep-deprived. After initially agreeing to medication, he attempted to le…

emergency medicinepsychiatrysystemdelaymethamphetamine
VIChome2022-10-27

Finding into death of Elizabeth Judith Robyn Wilms

29y · Female·Assault with blunt force injuries resulting in widespread bruising and traumatic…

Elizabeth Wilms, age 29, died between 1-5 July 2016 from fatal assault while in an abusive intimate relationship with Alexander Freeburn. Freeburn was the subject of an unexecuted NSW parole warrant for 541 days. The war…

forensic medicinetoxicologysystemdelaygamma hydroxybutyrate
TAShospital2022-10-26

Coroner's Finding: Carroll, Terence John

71y · Male·sepsis caused by mediastinal empyema (abscess) which complicated perforation of …

Terence Carroll, 71, died from sepsis and mediastinal empyema following oesophageal perforation during rigid oesophagoscopy for stricture dilation. Critical failures included: CT scan showing suspicious oesophageal thick…

ENT surgerygeneral surgerycommunicationdiagnostic
NSWcommunity2022-10-21

Inquest into the disappearance and suspected death of Theo Jean Hayez

18y · Male·Unable to determine

Theo Hayez, an 18-year-old Belgian backpacker, disappeared from Byron Bay on 31 May 2019 after being ejected from a nightclub for approaching intoxication. Digital evidence traced his movements via Google location data t…

systemdelay
NSWcommunity2022-10-21

Inquest into the death of Riley Christopher Shortland

8y · Male·multiple injuries sustained when struck by a truck on the M1 Pacific Motorway

Riley Shortland, an 8-year-old with severe autism spectrum disorder, global development delay, and ADHD, died when struck by a truck on the M1 Motorway after escaping from a vehicle during respite care. He removed his se…

occupational therapypsychologydiagnosticcommunication
NSWout-of-home care2022-10-21

Inquest into the death of Alex Raichman

11y · Male·Multiple injuries sustained when struck by train

Alex Raichman, 11, died when struck by a train after absconding from respite care at Civic Disability Services. Alex had autism, intellectual disability, and seizure disorder with documented absconding risk. Civic knew w…

paediatricspsychiatrysystemproceduralaripiprazole
NSWcommunity2022-10-21

Inquest into the death of Rachel Martin

28y · Female·Multiple injuries sustained when struck by a truck on the M1 Pacific Motorway

Rachel Martin, a 28-year-old SNAP support worker and pregnant woman, died attempting to prevent harm to a high-needs child (Riley) during respite care transport. While driving Riley home on the M1 Motorway, Riley exited …

social workpaediatricscommunicationsystem
VIChospital2022-10-18

Finding into death of Heather Jean Lucas

80y · Female·Anaphylaxis complicating chemotherapy for the treatment of metastatic fallopian …

Ms Heather Jean Lucas, 80-year-old woman with metastatic fallopian tube cancer, died from anaphylaxis during her third carboplatin chemotherapy infusion. She had experienced a documented Grade 2 hypersensitivity reaction…

oncologyemergency medicinemedicationcommunicationcarboplatin
VIChospital2022-10-18

Finding into death of Warren Douglas Frazer

45y · Male·Complications of VATS procedure for locally advanced right upper lobe lung adeno…

A 45-year-old man died from complications following VATS lobectomy for lung adenocarcinoma. During initial surgery, the tumour invaded the T6 vertebral body. The surgeon, faced with incomplete tumour resection or vertebr…

cardiothoracic surgeryneurosurgerydiagnosticdelay
VIChospital2022-10-18

Finding into death of Kenneth Ernest O'Brien

74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair

A 74-year-old man with significant cardiac history (atrial fibrillation, dilated cardiomyopathy, pacemaker) underwent elective umbilical hernia repair. Intraoperatively, unexpected ascites was discovered and partially dr…

general surgeryanaesthesiadiagnosticcommunicationapixaban
VICaged care2022-10-14

Finding into death of Beryl Eileen Brindley

74y · Female·Diabetic ketoacidosis

A 74-year-old woman with Type 1 diabetes died from diabetic ketoacidosis (DKA) in an aged care facility. Between 7-10 December 2016, her blood glucose levels remained persistently elevated (>33 mmol/L) despite escalating…

general practiceendocrinologydiagnosticcommunicationinsulin
NSWhospital2022-10-14

Inquest into the death of Malouvailoa Tafau

20y · Male·cardiac arrest due to complications of infective endocarditis against a backgrou…

Maluovailoa Tafau, a 20-year-old man in custody, died from cardiac arrest due to infective endocarditis complicated by rheumatic heart disease. He had submitted two patient self-referral forms (September 2016 and Februar…

cardiologyinfectious diseasesdiagnosticcommunicationflucloxacillin

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