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QLDhome2025-10-15

Inquest into the death of Tristian Jaemes Frahm

11y · Male·Brown snake envenomation

An 11-year-old boy died from brown snake envenomation after falling from a ride-on mower at a rural property. He exhibited early collapse symptoms (dizziness, vomiting, slurred speech) consistent with snake venom-induced…

emergency medicinetoxicologydiagnosticdelay
TASaged care2025-10-14

Coroner's Finding: de-identified XT

86y · Female·Hypostatic pneumonia due to the consequences of a right pubic rami fracture and …

An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…

geriatric medicineemergency medicinediagnosticcommunication
VIChome2025-10-09

Finding into death of Narelle Catherine Simmons

42y · Female·Haemothorax and pneumonia in the setting of acute and chronic chest injuries and…

Narelle Simmons, 42, died from haemothorax and pneumonia secondary to rib fractures, with contributing factors of hepatic cirrhosis, chronic alcoholism, and multiple drugs (methadone, methylamphetamine, diazepam, sertral…

forensic medicinegeneral practicediagnosticcommunicationmethadone
QLDhospital2025-10-08

Inquest into the death of Janis Ellen Doherty

57y · Female·Multi-organ failure due to drug-induced liver injury caused by sodium valproate …

Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nau…

neurologyhepatologydiagnosticmedicationsodium valproate
VIC2025-10-07

Finding into death of Anthony George Creaton

55y · Male·Acute myocardial infarction secondary to coronary artery thrombosis due to coron…

Anthony Creaton, 55, died of acute myocardial infarction due to coronary artery thrombosis and atherosclerosis in prison custody. He presented with chest pain on 13 November 2022 (twice) and again on 14 November, but nur…

cardiologygeneral practicediagnosticcommunicationgliclazide
QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…

emergency medicineinfectious diseasesdiagnosticdelayantacid
VIChospital2025-09-30

Finding into death of Robert Thoai Dao

73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…

A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…

paramedicineemergency medicinediagnosticprocedural
NSWmental health2025-09-29

Inquest into the death of BQ

23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging

BQ was a 23-year-old Aboriginal woman who died by hanging on the Paringa Ward at Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and bo…

psychiatryemergency medicinediagnosticcommunication
VIChospital2025-09-25

Finding into death of Dio Miranda Katiana Kemp

3y · Female·Streptococcus pyogenes septicaemia

A three-year-old girl with Down syndrome died from Group A Streptococcus septicaemia after a 10-day illness. She presented four times to hospital (ED and rapid review clinic) over three days with fever, rash, and diarrho…

emergency medicinepaediatricsdiagnosticcommunication
VIC2025-09-24

Finding into death of Bryan Pham

24y · Male·multiple injuries and chest compression asphyxia (train strike)

Bryan Pham, 24, died by suicide via train strike on 2 June 2020, two days after release from remand custody. He had schizophrenia, substance use disorder, and was recently incarcerated for assault and FVIO breach. While …

psychiatrycorrectional healthcommunicationsystemmethamphetamine
VICcommunity2025-09-17

Finding into death of Manpreet Kaur

24y · Female·Pulmonary and miliary tuberculosis

Manpreet Kaur, a 24-year-old Indian national on a student visa, died of pulmonary and miliary tuberculosis on 20 June 2024 at Melbourne Airport. She had been symptomatic for months, presenting to a GP on 19 May 2024 with…

general practicerespiratory medicinediagnosticsystem
VIChome2025-09-12

Finding into death of Baby H

0y · Female·Unascertained

Baby H was born at home on 21 September 2022 following an unassisted birth (freebirth) without medical oversight. The mother had received no antenatal care despite being unaware of the actual gestational age. The baby sh…

obstetricsneonatologydiagnosticdelay
SAaged care2025-09-11

Coroner's Finding: Glenn, Millicent

89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…

An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…

general practicegeriatric medicinemedicationdiagnosticgentamicin
NSWhome2025-09-11

Inquest into the death of H GM

0y · Female·Unascertained

A 9-month-old girl died suddenly on 23 July 2018 following multiple head injuries from blunt force trauma sustained shortly before death. She had presented to medical practitioners multiple times in the preceding weeks w…

paediatricsemergency medicinediagnostic
NSWprison2025-09-10

Inquest into the death of RD

70y · Male·death by hanging, self-inflicted

A 70-year-old man died by hanging in prison while serving a sentence for child sexual offences. He had previously attempted suicide in 2017 when initially charged, and was subsequently treated with antidepressants and ps…

psychiatrygeneral practicecommunicationsystemsertraline
NSWcommunity2025-09-08

Inquest into the death of Rohan Lloyd

37y · Male·Combined effects of presumed heavy metal poisoning from an unknown material and …

A 37-year-old man with schizophrenia died between 14–18 August 2020 in bushland near Whiteman Creek NSW, from presumed heavy metal poisoning and freshwater drowning. He was experiencing a psychotic episode related to unm…

psychiatrygeneral practicediagnosticmedicationrisperidone
VIChospital2025-09-03

Finding into death of Olivia Alexandra Evans

15y · Female·Paracetamol toxicity in the setting of Anorexia Nervosa

Olivia Evans, 15, died from paracetamol toxicity in the setting of anorexia nervosa after intentionally overdosing. She had 38 inpatient admissions over two years with escalating food refusal, self-harm, and suicidal beh…

psychiatrypaediatricsdiagnosticsystemparacetamol
VIChome2025-09-02

Finding into death of Mr IKL

29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…

A 29-year-old man died from mixed drug toxicity involving multiple CNS depressants. His GP, Dr X, had maintained an inappropriate three-year sexual relationship with the patient while prescribing escalating doses of opio…

general practicepsychiatrydiagnosticmedicationgabapentin
VICcommunity2025-09-01

Finding into death of Ms FSZ

32y · Female·Compression of the neck

FSZ, a 32-year-old woman, was killed by her intimate partner NLU through compression of the neck (strangulation) on 24 April 2019. This coronial finding identifies multiple systemic failures in family violence response a…

psychiatryemergency medicinediagnosticcommunicationolanzapine
NT2025-08-29

Inquest into the death of Raylene Dick, David Hardy and Karen Bading

46y · Female·Hepatic encephalopathy due to decompensated Child-Pugh C cirrhosis and meningiti…

This combined coronial finding examines three deaths at the Centre for National Resilience (CNR), a COVID-19 quarantine facility in Howard Springs. Ms Dick died from rapidly progressive melioidosis. David Hardy died from…

infectious diseasesintensive carediagnosticsystem
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