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SAcommunityNew2026-08-21

Coroner's Finding: Holden, Richard Arthur

74y · Male·Pulmonary thromboembolism due to right deep vein thrombosis

Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond t…

general practiceemergency medicinediagnosticdelaysalbutamol
VICcommunityNew2026-08-17

Finding into death of Guy Christian Mason

48y · Male·Pulmonary thromboembolism

Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…

emergency medicinegeneral surgerydiagnosticsystemenoxaparin
SAhome2026-08-12

Coroner's Finding: Sylvia, Kate Marie

32y · Female·cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage

Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. mis…

paramedicinegeneral medicinediagnosticcommunicationoral contraceptive pill
NSW2026-08-07

Inquest into the death of Amanawel Ayai

23y · Male·complications of bowel obstruction by adhesions

A 23-year-old man in lawful custody at Parklea Correctional Centre presented on 7 January 2022 with severe chest pain, abdominal pain, vomiting, and dehydration, with a significant history of previous abdominal surgery a…

correctional healthgeneral practicediagnosticcommunicationmetoclopramide
NSW2026-07-10

Inquest into the death of Fredrick Elrezz

32y · Male·Hanging (deliberately self-inflicted)

Fredrick Elrezz, 32, died by hanging in segregation at Parklea Correctional Centre on 25 September 2020. Arrested on 1-2 September after stabbing police in an apparent suicide-by-cop attempt, Fred explicitly stated his i…

correctional healthpsychiatrycommunicationsystem
NSW2026-07-10

Inquest into the death of CG

61y · Male·Exsanguination from sharp force injuries to both arms, dissecting the veins of t…

CG, aged 61, died in Parklea Correctional Centre on 18 May 2024 from hemorrhage due to self-inflicted sharp force injuries. The coroner found multiple clinical and system failures contributed substantially to the death. …

general practiceemergency medicinesystemcommunicationoxycodone
QLDhospital2026-07-07

Inquest into the death of Maxwell John Beever

83y · Male·Metastatic melanoma

Maxwell John Beever, aged 83, died from metastatic melanoma on 8 July 2022 while in custody at Robina Hospital. A suspicious skin lesion was documented on 26 February 2021 but not investigated until 26 June 2021, delayin…

emergency medicinegeneral medicinedelaydiagnosticoxycodone
VIChospital2026-07-01

Finding into death of HJW

69y · Female·Urosepsis secondary to anuric acute renal failure and corona radiata infarct; co…

A 69-year-old diabetic woman presented to Maroondah Hospital Emergency Department on 9 June 2024 with severe right-sided abdominal pain and vomiting. CT imaging at 10:00am confirmed emphysematous pyelitis (gas-forming ki…

emergency medicinegeneral medicinediagnosticdelayfentanyl
QLDcommunity2026-06-26

Inquest into the death of Wayne Thomas Kerle

68y · Male·Cardiac arrest - unascertained etiology with multiple contributing factors inclu…

Wayne Thomas Kerle, 68, was arrested at his home for cannabis possession. Queensland Ambulance Service paramedics assessed him when he reported respiratory distress but cleared him for police custody after a limited exam…

paramedicineemergency medicinediagnosticproceduraldiazepam
SAaged care2026-06-19

Coroner's Finding: Fowle, Colleen Margaret

78y · Female·urinary tract infection and pneumonia on a background of facial fractures and de…

A 78-year-old woman with mixed dementia living in aged care suffered an unwitnessed fall on 22 March 2023, sustaining facial fractures and eye laceration. The fractures were not identified during her initial hospital ass…

general practicegeriatric medicinediagnostic
NSW2026-06-11

Inquest into the death of Dictor Dongrin

29y · Male·Cardiac arrhythmia in the context of alcohol withdrawal and chronic alcohol misu…

A 29-year-old man died from cardiac arrhythmia in the context of severe alcohol withdrawal at a correctional facility. Initial assessment correctly identified moderate-to-severe withdrawal (AWS score 8) with seizure hist…

addiction medicinecorrectional healthdiagnosticmedicationalcohol
QLDaged care2026-06-09

Non-inquest findings into the death of Mr M (2 of 3 linked pressure injury cases)

82y · Male·Multiorgan failure due to neurological failure due to Parkinson's disease with a…

Mr M, aged 82, with advanced Parkinson's disease and dementia, developed severe pressure injuries while in residential aged care. A significant sacral pressure wound went undetected until mid-December 2023 and rapidly de…

general practiceemergency medicinediagnosticcommunicationcefalexin
VICcommunity2026-05-07

Finding into death of Elizabeth Susan Edwina Ferris

44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…

Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…

psychiatryintensive carediagnosticcommunicationheroin
VICaged care2026-05-06

Finding into death of Cornelia Groot

87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…

An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…

geriatric medicineemergency medicinediagnosticcommunicationoxycodone
VIChospital2026-04-16

Finding into death of Damien Mark Stone

53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures

Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…

emergency medicineneurologydiagnosticcommunicationoxycodone
VIChome2026-04-14

Finding into death of James Thomas Reilly

86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall

James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…

emergency medicinegeneral medicinediagnosticmedicationenoxaparin
TASmental health2026-04-13

Coroner's Finding: de-identified DR

41y · Male·asphyxia due to neck compression following ligature suspension (hanging)

DR was a 41-year-old man with bipolar disorder, severe alcohol dependence, and multiple psychosocial stressors including family violence, homelessness, and financial crisis. In October 2023, he presented with acute mania…

psychiatryemergency medicinediagnosticcommunicationolanzapine
QLDhospital2026-03-31

Inquest into the death of Robyn Ann Beale

78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …

A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…

general surgeryanaesthesiadiagnosticcommunicationoxycodone
QLD2026-03-31

Inquest into the death of Kyle James Gallagher

22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…

Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…

ENT surgeryradiologydiagnosticcommunicationdiazepam
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
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