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VIC2022-09-02

Finding into death of Bazouni Bazouni

21y · Male·Hypoxic brain injury in the setting of drug toxicity

21-year-old Bazouni Bazouni died from hypoxic brain injury following methamphetamine toxicity ingested at Port Philip Prison. While the coroner concluded the death was not preventable given the excessive drug ingestion, …

emergency medicinecorrectional healthdiagnosticcommunicationmethamphetamine
VIChospital2022-08-31

Finding into death of Cindy Jane Martin

40y · Female·Complications of WHO Class III Obesity

Cindy Jane Martin, a 40-year-old Aboriginal woman with treatment-resistant schizophrenia, WHO Class III obesity, and obstructive sleep apnoea, died of sudden cardiac complications seven days after psychiatric admission. …

psychiatryrespiratory medicinesystemdelaysodium valproate
VIChome2022-08-31

Finding into death of B L

28y · Male·neck compression consequent upon hanging

A 28-year-old man with severe personality disorder, substance use history, and recent suicidal ideation died by hanging. He was admitted to mental health services on 25 February 2019 after suicide threats and high-lethal…

psychiatryemergency medicinecommunicationsystemsodium valproate
VIChome2022-08-30

Finding into death of Boe Luke Memery

24y · Male·Neck compression in the circumstances of hanging

Boe Luke Memery, a 24-year-old Aboriginal man, died by hanging on 19 May 2019 following a relationship breakdown. He had a history of depression, self-harm, and previous suicide attempts. In the weeks before his death, h…

psychiatrygeneral practicedocumentationcommunicationvenlafaxine
VIChospital2022-08-29

Finding into death of Helen Welsh

63y · Female·Escherichia coli septicaemia in a lady with multiple comorbidities

Helen Welsh, 63, died from E. coli septicaemia with multiple comorbidities. She presented with respiratory symptoms and underwent bronchoscopy. On discharge day, she deteriorated with fever, altered consciousness, and hy…

cardiothoracic surgeryemergency medicinedelaydiagnosticcarbimazole
VIChospital2022-08-26

Finding into death of Jessica Higgins

33y · Female·Hypoxic ischaemic encephalopathy complicating mixed drug toxicity

Jessica Higgins, a 33-year-old woman with chronic pain and opioid dependence, died from hypoxic ischaemic encephalopathy following mixed drug toxicity. She underwent a ketamine infusion with opioid rotation from oxycodon…

pain medicineaddiction medicinecommunicationsystemmethadone
NSW2022-08-26

Inquest into the death of LAK

19y · Male·Hanging

LAK, a 19-year-old Aboriginal man, died by suicide at a community rehabilitation facility after a complex mental health journey involving forensic orders and psychosis. Key clinical lessons include: recognising vulnerabi…

psychiatryaddiction medicinecommunicationsystem
VIChospital2022-08-19

Finding into death of Ruth Ann McKenna

62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…

A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy fo…

gynaecologyanaesthesiadiagnosticsystemmetaraminol
WAcommunity2022-08-18

Inquest into the Suspected Death of Nicholas PAVLIDIS

Male·Unknown - presumed deceased from exposure, heat exhaustion, or injury during unp…

Nicholas Pavlidis disappeared in October 2015 from Yanchep, Western Australia. He was last seen alive on 14 October 2015 by a friend. His vehicle was found abandoned in a pine plantation on 24 October 2015. Despite exten…

general practicepsychologysystemdelayfluoxetine
NSW2022-08-18

Inquest into the death of Gavin Ellis

31y · Male·hanging

Mr Gavin Ellis, 31 years old, died by hanging in custody on 2 April 2017 at the Metropolitan Remand and Reception Centre, Silverwater. He had a chronic treatment-resistant schizophrenic illness with extensive self-harm h…

psychiatrycorrectional healthdiagnosticcommunicationaripiprazole
NSWhospital2022-08-17

Inquest into the death of Robert Bischard

75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…

Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…

orthopaedic surgerycardiologydiagnosticsystemfurosemide
TAShome2022-08-11

Coroner's Finding: Youd, Diane Maree

60y · Female·undetermined; natural causes not excluded (possible paraganglioma infarction, pn…

A 60-year-old woman with depression, recent acute kidney injury from dehydration, and suicidal ideation was discharged from hospital on 27 August 2021 after psychiatric improvement. She was prescribed increased Sertralin…

psychiatrygeneral practicecommunicationdelaysertraline
VIChome2022-08-11

Finding into death of Christopher David French Hunter

31y · Male·hanging

Christopher Hunter, a 31-year-old with emerging paranoid psychotic disorder, was admitted to Delmont Private Hospital for 3 days before requesting discharge against medical advice on 9 June 2015. A senior registrar (Dr T…

psychiatrycommunicationsystemolanzapine
VICcommunity2022-08-10

Finding into death of John Lester Costello

59y · Male·Unascertained

John Lester Costello, a 59-year-old itinerant fruit picker, disappeared from Cobram, Victoria on or after 9 January 1997 and has not been seen or heard from since. He had a history of mental health vulnerability, depress…

delaysystem
TAShospital2022-08-09

Coroner's Finding: Tedmanson, Wayne Douglas

76y · Male·ischaemic heart disease following hyperglycaemic hyperosmolar syndrome (HHS) due…

Wayne Douglas Tedmanson, aged 76, died from ischaemic heart disease following hyperglycaemic hyperosmolar syndrome (HHS), a complication of type 2 diabetes mellitus. Clinical lessons include recognising HHS presentations…

emergency medicinegeneral medicinedelay
VIChome2022-08-08

Finding into death of Kim Michelle Cooper

47y · Female·Mixed drug toxicity (pregabalin, oxycodone and mirtazapine)

A 47-year-old woman died from mixed drug toxicity involving pregabalin, oxycodone, and mirtazapine. She had chronic pain, anxiety, and depression, and attended a medical clinic frequently. Over five days before her death…

general practiceaddiction medicinemedicationsystempregabalin
WA2022-08-05

Inquest into the Death of Michael James HARDIE

41y · Male·haemothorax due to ruptured thoracic aortic aneurysm in a man with Marfan syndro…

A 41-year-old man with Marfan syndrome and a thoracic aortic aneurysm managed conservatively with blood pressure medications died from aneurysm rupture while imprisoned. Methylamphetamine in his system significantly elev…

cardiologyvascular surgerycommunicationsystemmethamphetamine
WAhospital2022-08-02

Inquest into the Death of Henry ALLEN

60y · Male·sepsis and aspiration pneumonia in a man with oral squamous cell carcinoma and m…

Henry Allen, a 60-year-old man with oral squamous cell carcinoma, lung cancer, and multiple comorbidities died from sepsis and aspiration pneumonia while in prison custody at Fiona Stanley Hospital. He received appropria…

oncologypalliative caresystemdelayoxycodone
NSWcommunity2022-08-02

Inquest into the disappearance and suspected death of Kenneth Klees

37y · Male·Unascertained

Kenneth Klees, aged 37, disappeared on 1 February 2021 and was found deceased on Mollymook beach on 26 February 2021. He had a history of depression, anxiety, poorly controlled type 2 diabetes, and obsessive-compulsive d…

general practicepsychiatrycommunicationsystem
VICcommunity2022-08-01

Finding into death of X Y

53y · Male·Multiple gunshot injuries

53-year-old man with longstanding unresolved childhood trauma, affected by COVID-19 pandemic restrictions, developed acute paranoia and anxiety. Believed people were hacking his devices and tracking him. When school welf…

psychiatryemergency medicinecommunicationsystem

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