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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
NTcommunity2025-07-07

Inquest into the death of Kumanjayi Walker

19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …

Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…

emergency medicinegeneral practicediagnosticprocedural
VIChome2025-06-24

Finding into death of Jessica Geddes

27y · Female·Complications of multiple blunt force injuries

Jessica Geddes, 27, was killed by her partner Robert Rickerby through multiple blunt force injuries on 6 November 2020. The autopsy revealed extensive acute, subacute and chronic injuries inconsistent with accidental tra…

general practicepsychiatrydiagnosticsystemmethamphetamine
NSW2025-05-02

Inquest into the death of Emmett Brown

25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…

Emmett Brown, a 25-year-old First Nations man, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvida…

correctional healthaddiction medicinediagnosticsystemmethadone
TAShospital2025-04-29

Coroner's Finding: de-identified OQ

41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…

A 41-year-old woman died from frontal lobe ischaemic infarcts caused by cerebral vasospasm complicating subarachnoid haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days wit…

emergency medicineneurosurgerydiagnosticcommunicationchlorpromazine
TAScommunity2025-04-24

Coroner's Finding: de-identified FG

53y · Male·Acute myocardial infarction due to triple vessel atherosclerosis and thrombosis …

A 53-year-old man with chest pain on exertion presented to his GP in March 2022. Initial investigations (blood tests, chest X-ray) were ordered but follow-up was delayed until July 2022. A cardiology referral was made, a…

cardiologygeneral practicediagnosticdelayrosuvastatin
SAmental health2025-04-17

Coroner's Finding: Furlan, Mark John & Miller, Richard John

50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…

Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…

psychiatryemergency medicinediagnosticcommunicationescitalopram
QLDaged care2025-04-17

Non-inquest findings into the death of Mr H.

89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…

An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …

geriatric medicinegeneral practicediagnosticcommunicationmacrogol
WAhospital2025-04-17

Inquest into the Death of Colin Stanley Francis NICHOLSON

69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…

Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…

haematologygeneral practicediagnosticcommunicationparacetamol
NSWhospital2025-04-16

Inquest into the death of Michael Sanderson

53y · Male·Metastatic pancreatic carcinoma

Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …

general practicepathologydiagnosticcommunicationryzodeg 70/30
WAprison2025-04-10

Inquest into the Death of Dannielle Stacey LOWE

41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm

Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…

emergency medicineneurosurgerydiagnosticcommunicationparacetamol
TASaged care2025-04-08

Coroner's Finding: Zito, Adelina

93y · Female·acute right lower limb ischaemia

Adelina Zito, a 93-year-old resident of an aged care facility, died from acute limb ischaemia after a 6-7 day delay in escalating her care. She developed right leg pain around 26-28 July 2022 that worsened despite parace…

geriatric medicinegeneral practicediagnosticsystemparacetamol
VIChospital2025-04-01

Finding into death of ZSQ

81y · Male·Community acquired pneumonia in a man with acute on chronic renal failure

An 81-year-old man with chronic respiratory disease and renal failure died from community-acquired pneumonia complicated by acute-on-chronic renal failure. He presented to hospital on 25 April 2023 with respiratory failu…

intensive carerespiratory medicinediagnosticdelayadrenaline
VICmental health2025-03-04

Finding into death of Jamie Alexander Knowles

24y · Male·neck compression secondary to hanging

Jamie Knowles, a 24-year-old with schizophrenia, died by suicide on 24 June 2024 while on an inpatient temporary treatment order at Kerferd Unit mental health service in Victoria. He was granted one hour of unescorted le…

psychiatrygeneral practicesystemcommunicationclozapine
VIChospital2025-02-26

Finding into death of CFT

78y · Female·Bronchopneumonia

CFT, a 78-year-old woman with chronic schizophrenia, intellectual disability, and dementia, died of bronchopneumonia with hypothermia and coronary atherosclerosis. She lived with her nephew RDS who was her carer. Multipl…

geriatric medicinegeneral practicediagnosticsystem
NSWhospital2025-02-21

Inquest into the death of David Freeman

46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…

A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…

emergency medicinegeneral practicediagnosticmedicationaspirin
NSWaged care2025-01-24

Inquest into the deaths at Newmarch House

Unknown·COVID-19 infection with various comorbidities as contributing factors

This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…

geriatric medicineinfectious diseasessystemdiagnosticmorphine
VICcommunity2025-01-23

Finding into death of Bariyow Mohamed Hussein

50y · Male·Unascertained

A 50-year-old homeless man from South Sudan was found deceased in a disused office space at a car wrecking workshop in Braybrook, Victoria. He had been medically obese with an unhealthy lifestyle including alcohol consum…

emergency medicinegeneral practicediagnostic
VIChome2025-01-09

Finding into death of C M

25y · Female·Neck compression secondary to hanging

CM, a 25-year-old woman experiencing depression, anxiety, and substance misuse, died by suicide while in an intimate partner relationship characterised by documented family violence. She presented to hospital multiple ti…

emergency medicinepsychiatrydiagnosticsystemalprazolam
VICaged care2025-01-06

Finding into death of C M

55y · Male·Diabetic ketoacidosis

CM, a 55-year-old man with severe congenital disabilities and Type 2 Diabetes, died from diabetic ketoacidosis while residing in a disability support facility. In the week preceding death, he experienced reduced appetite…

general practiceemergency medicinediagnosticlevetiracetam
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