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VIChome2026-04-30

Finding into death of Nick Panagiotopoulos

47y · Male·Acute myocardial infarction due to thrombotic occlusion of the right coronary ar…

Nick Panagiotopoulos, a 47-year-old man, suffered a fatal acute myocardial infarction (heart attack) on 16 October 2021 at home in Preston, Victoria. His family made five calls to Triple Zero (000) requesting emergency a…

cardiologyemergency medicinesystemdelay
VIChospital2026-04-28

Finding into death of Ronald William Beaumont

74y · Male·Acute myocardial infarction complicated by multiple organ failure

Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…

cardiologyorthopaedic surgerymedicationcommunicationaspirin
QLDhospital2026-04-14

Inquest into the death of Francis Michael Fahey

70y · Male·Metastatic melanoma with ischaemic heart disease as a contributing condition

Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…

oncologygeneral medicinesystemdelayimmunotherapy
VICcommunity2026-03-27

Finding into death of Sacha Timothee Louis Lefebvre

52y · Male·Complications of chronic cardiac failure in the setting of ischaemic heart disea…

Sacha Timothee Louis Lefebvre, aged 52, died from complications of chronic cardiac failure with ischaemic heart disease and chronic anaemia whilst sleeping rough at Hawthorn Library. He had multiple chronic conditions in…

cardiologyemergency medicinesystemdelaymethamphetamine
NSW2026-03-06

Inquest into the death of Gregory Merriman

58y · Male·acute myocardial infarction caused by ischaemic heart disease

Gregory Merriman, a 58-year-old Aboriginal man, died from acute myocardial infarction caused by advanced ischaemic heart disease while in custody at Metropolitan Reception and Remand Centre on 27 December 2022. He experi…

cardiologygeneral practicediagnosticcommunicationperindopril
QLDhospital2026-02-18

Non-inquest findings into the death of Mr C

62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…

A 62-year-old man died from intraoperative haemorrhage during surgery for a renal tumour initially diagnosed as benign anastomosing haemangioma on biopsy but found at autopsy to be metastatic clear cell renal cell carcin…

urologygeneral surgerydiagnosticcommunicationmetaraminol
NThospital2026-02-10

Inquest into the death of Martin Leach

67y · Male·Congestive cardiac failure

Martin Leach, a 67-year-old man serving a life sentence, died from congestive cardiac failure with atrial fibrillation and dilated cardiomyopathy. He had consistently refused life-prolonging medical treatments and comple…

emergency medicinecardiologysystemcommunicationmorphine
VIChome2026-02-03

Finding into death of Jeffrey Thomas Wilson

76y · Male·Effects of fire due to home oxygen ignition in the setting of smoking; lung canc…

A 76-year-old man with lung cancer and mesothelioma died from thermal injuries sustained when his home oxygen ignited while smoking. He had been discharged on self-funded home oxygen despite a recent smoking history, aft…

respiratory medicinepalliative caresystemdelay
WA2026-02-02

Inquest into the Death of Joshua Fredrik VAN MALSSEN

24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…

Joshua Fredrik Van Malssen, a 24-year-old man with Sotos syndrome, complex cardiac disease, asthma, and obesity, died from cardiac arrest after being restrained in the prone position during a lawful arrest by Public Tran…

cardiologyrespiratory medicinecommunicationsystemloratadine
WAhospital2026-01-08

Inquest into the Death of Lewis Walter WARD

33y · Male·Complications of out of hospital cardiac arrest in a man with atherosclerotic ca…

A 33-year-old Indigenous man with Type 2 diabetes, hypertension and dyslipidemia collapsed while playing football in a prison in July 2023, sustaining an out-of-hospital cardiac arrest from which he did not recover. Auto…

cardiologyintensive caresystemcommunication
NSWhospital2025-12-19

Inquest into the death of JBO

27y · Female·Cardiac arrhythmia (first confirmed as ventricular fibrillation) of unascertaine…

A 27-year-old Aboriginal woman suffered sudden cardiac arrhythmia (ventricular fibrillation) immediately after recording video evidence of a suspected breach of her protective apprehended personal violence order (APVO). …

emergency medicinecardiologycommunicationsystemamiodarone
TAShospital2025-12-09

Coroner's Finding: de-identified EM

76y · Female·sepsis as a result of myocarditis and tricuspid valve endocarditis (infective en…

A 76-year-old woman with vascular dementia and emphysema was admitted with sepsis of unknown origin, treated with antibiotics, and discharged after 12 days with improving symptoms. She re-presented 14 days later with rec…

emergency medicinecardiologydiagnosticcommunicationantibiotics
WAhospital2025-11-27

Inquest into the Death of Stephen Joseph SCHIPP

58y · Male·complications of oesophageal cancer, with terminal palliative care

Stephen Joseph Schipp, a 58-year-old sentenced prisoner, died from complications of oesophageal cancer with terminal palliative care at Bunbury Regional Hospital. He had been diagnosed with oesophageal carcinoma in Janua…

oncologypalliative caresystemdelaychemotherapy
NSW2025-10-22

Inquest into the Death of Frank Dwayne COLEMAN

43y · Male·methadone toxicity

Frank Coleman, a 43-year-old First Nations man, died of methadone toxicity after being supplied diverted methadone by another inmate while imprisoned at Long Bay Correctional Complex. Mr Coleman had repeatedly requested …

addiction medicinepsychiatrydiagnosticsystemmethadone
SAcommunity2025-10-20

Coroner's Finding: Kennedy, John Douglas

65y · Male·Ischaemic heart disease on a background of hypertension

John Kennedy, 65, died from ischaemic heart disease with hypertension on 16 April 2020 after a 24-minute delay in ambulance dispatch. He called triple zero at 00:19 with severe chest pain and difficulty breathing (Priori…

emergency medicinecardiologycommunicationsystematenolol
SAhospital2025-07-31

Coroner's Finding: Panella, Anna Vincenza and Skeffington, Bernard Anthony and Jessett, Graham Henry

Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…

Three South Australians died following extended waits on ambulance ramps outside metropolitan hospitals. Anna Panella (76) died from pulmonary thromboembolism; Bernard Skeffington (89) died from aspiration pneumonia afte…

emergency medicinecardiologycommunicationsystem
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
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
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
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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