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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
WA2026-04-28

Inquest into the Death of Corey Desmond DEVREE

41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…

Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…

psychiatrygeneral practicediagnosticcommunication
NSWhome2026-04-01

Inquest into the death of EJJ

39y · Male·Hanging

A 39-year-old man died by hanging on 16 February 2023 at his home in St Marys, NSW. His mother requested a police welfare check at 8:40pm after he posted a suicide note on Facebook at 2:30pm. Police attended twice (11pm …

psychiatryforensic medicinecommunicationsystemdiazepam
SAhospital2026-03-30

Coroner's Finding: Chadha, Hemant and Battagodage, Sachintha Nandula

Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…

Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…

emergency medicinegeneral practicediagnosticcommunicationdiazepam
VIChome2026-03-19

Finding into death of Aisha Natasha Khan

44y · Female·Mixed alcohol and drug toxicity (tapentadol, diazepam, mirtazapine, amitriptylin…

Aisha Natasha Khan, 44, died from mixed alcohol and drug toxicity following an intentional polypharmacy overdose with alcohol consumption. She had a history of depression, alcohol use disorder, chronic pain, and two prio…

psychiatryemergency medicinesystemdelaytapentadol
VIChospital2026-02-05

Finding into death of Max Peter McKenzie

15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…

Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…

emergency medicineparamedicinedelaycommunicationadrenaline
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 3

Multiple penetrating knife wounds with hemorrhagic shock and traumatic cardiac a…

On 13 April 2024, Joel Cauchi, with inadequately managed treatment-resistant schizophrenia, stabbed six people to death and injured ten others at Westfield Bondi Junction shopping centre in Sydney. The coroner found Cauc…

emergency medicineparamedicinesystemcommunication
QLDhome2026-02-03

Inquest into the death of Bridie Gilligan

42y · Female·Hypoxic brain injury due to choking on food, in a person with Cornelia de Lange …

Bridie Gilligan, aged 42 with Cornelia de Lange Syndrome, profound intellectual disability and dysphagia, died from hypoxic brain injury after choking on a Yumbo burger at her SIL home on 29 April 2021. Her support worke…

speech pathologydieteticscommunicationsystem
VIChome2025-12-19

Finding into death of Narisha Faye Cash

41y · Female·Combined Drug Toxicity (ethanol and benzodiazepine)

Narisha Faye Cash, 41-year-old Aboriginal woman, died on 26 March 2020 from combined drug toxicity (ethanol and benzodiazepines) following an inadequate emergency services response to her mental health crisis. She called…

emergency medicinepsychiatrysystemcommunicationalcohol
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
NSWcommunity2025-09-24

Inquest into the death of Matthew Richard Lothian

37y · Male·self-inflicted gunshot wound to the head and neck

Matthew Lothian, aged 37, died from a self-inflicted gunshot wound to the head and neck on 6 January 2021 in Wollongong. He was on medical escort from custody when he seized the firearm from Correctional Services Officer…

psychiatrycorrectional healthsystemcommunicationmethadone
NSWhome2025-09-04

Inquest into the death of Baby MA

0y · Female·Unascertained

An unnamed full-term baby was found deceased at Edmondson Park on 19 February 2022, hours after birth. The mother attended Liverpool Hospital with only a placenta, initially denying pregnancy and the baby's existence. Po…

obstetricsemergency medicinedelay
NSWhome2025-08-28

Inquest into the death of KBS

1y · Male·Blunt force abdominal trauma; laceration of spleen with intra-abdominal haemorrh…

A 14-month-old Aboriginal boy died from blunt force abdominal trauma with a splenic laceration on 13 January 2019. He had multiple injuries documented at autopsy including rib fractures, extensive bruising, and patterned…

paediatricsforensic medicinecommunicationsystemcannabis
VIChome2025-08-20

Finding into death of GFD

2y · Male·Complications of malnutrition

GFD, a 2-year-old boy, died from complications of malnutrition and dehydration on 3 July 2021. Post-mortem examination revealed severe undernutrition, chronic malnutrition, and significant dehydration with hypernatraemia…

paediatricsforensic medicinesystemcommunication
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
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
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
VIChome2025-06-02

Finding into death of Christina Lackmann

32y · Female·Caffeine toxicity

32-year-old woman died from caffeine toxicity after ingesting caffeine tablets. She called 000 at 7:49 pm reporting dizziness and numbness but was triaged as non-urgent Code 3. Unable to connect with a secondary triage p…

emergency medicinetoxicologytriagesystemcaffeine
SA2025-05-20

Coroner's Finding: Pham, Duy Ngoc

35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…

35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…

emergency medicinegeneral practicedelaycommunicationmethamphetamine
NSWhome2025-05-09

Inquest into the death of Malcolm Brown

33y · Male·sharp force injuries of the neck

Malcolm Brown, a 33-year-old Aboriginal man with a history of methamphetamine use, mental health crisis, and self-harm threats, died from sharp force injuries to his neck on 29 June 2022 following a NSW Police operation.…

psychiatrytoxicologycommunicationdelaymethamphetamine
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