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VIChospital2026-03-13

Finding into death of Wayne Ronald Watson

61y · Male·Intracranial haemorrhage and myocardial infarct

A 61-year-old man with extensive cardiac disease collapsed at a supermarket, striking his head and losing consciousness for less than 10 seconds. Paramedics identified STEMI and administered heparin on advice from Austin…

cardiologyemergency medicinediagnosticcommunicationheparin
VIChospital2026-01-08

Finding into death of Malakai Cross-De Jesus

0y · Male·Complications following forceps delivery

A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
NSWhospital2025-12-08

Inquest into the death of Katrina McGrady

43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm

Trina McGrady, a 43-year-old Goomeroi woman, died from subarachnoid haemorrhage due to a ruptured berry aneurysm on 15 September 2020. She had been admitted to John Hunter Hospital following incidental discovery of two l…

neurosurgeryradiologycommunicationdiagnosticaspirin
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
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
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…

emergency medicineintensive carediagnosticproceduralhydromorphone
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
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
TAShospital2025-03-17

Coroner's Finding: Phillips, Helen Lynette

77y · Female·intracranial haemorrhage (subdural, intraventricular and brainstem)

A 77-year-old woman fell from a ladder on 12 December 2022, suffering loss of consciousness and rib fractures. No brain CT scan was performed at Mersey Community Hospital despite the mechanism of injury and unconsciousne…

emergency medicinecardiologydiagnosticdelaythrombolytic agents
VIC2024-12-16

Finding into death of Caroline Monique Hall

52y · Female·Spinal injuries sustained in falls in a woman with multiple medical comorbiditie…

Caroline Monique Hall, a 52-year-old woman with intellectual disability, epilepsy, schizophrenia, and multiple comorbidities living in supported disability accommodation, died from spinal injuries sustained in falls. She…

general practiceemergency medicinediagnosticdelaymorphine
TAShospital2024-10-18

Coroner's Finding: Long, Leonard

73y · Male·subdural haematoma from fall

Leonard Athol Long, a 73-year-old on warfarin for mechanical mitral valve replacement, fell twice during hospitalization for urinary tract infection. He was on SMZ-TMP antibiotics, which interact significantly with warfa…

general medicineemergency medicinediagnosticsystemwarfarin
VIC2024-09-19

Finding into death of George Diamond

18y · Male·complications of acute on chronic subdural haemorrhage (operated) in the setting…

George Diamond, 18, died from acute-on-chronic subdural haemorrhage sustained during boxing sparring on 18 February 2019. He had suffered a head injury during sparring on 25 October 2018, presenting with headache, nausea…

general practiceemergency medicinediagnosticdelayparacetamol
TAShospital2024-03-27

Coroner's Finding: Leary, Kane

17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…

Kane Mathew Leary, 17, died from a stroke (left middle cerebral artery infarction) following a motorbike collision. The critical clinical lesson involves a missed diagnosis of left internal carotid artery dissection on i…

emergency medicineneurosurgerydiagnosticcommunicationmorphine
VIChome2024-01-16

Finding into death of Kieran Joseph McGuinness

37y · Male·Sudden unexpected death in epilepsy (SUDEP) in the setting of acquired brain inj…

Kieran McGuinness, 37, died of sudden unexpected death in epilepsy (SUDEP) following acquired brain injury with post-traumatic epilepsy. He was found unresponsive on his apartment floor on 11 September 2022, having been …

neurosurgeryneurologydiagnosticcommunicationlevetiracetam
SAhome2023-12-06

Coroner's Finding: Cullen, Jason Mark

37y · Male·mixed drug toxicity with fentanyl as the principal agent

37-year-old Jason Cullen died from mixed drug toxicity with fentanyl as the principal agent. He had chronic idiopathic intracranial hypertension requiring multiple neurosurgeries and was prescribed opioids and benzodiaze…

neurosurgerypsychiatrycommunicationsystemfentanyl
VIChospital2023-08-01

Finding into death of Michele Valentino

81y · Male·Head injury sustained in a fall

Michele Valentino, 81, died from a head injury sustained in a fall on 20 December 2019, with death occurring on 24 December 2019. A CT angiogram at 3:45pm showed worsening intraventricular haemorrhage (IVH) that was not …

emergency medicineradiologydiagnosticcommunicationaspirin
VIChospital2023-07-19

Finding into death of Daryl William Nioa

74y · Male·Pulmonary thromboembolism secondary to deep vein thrombosis in the setting of re…

A 74-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis following a cervical spinal fracture. He presented to rural ED with mental health concerns, was restrained by security guards after …

emergency medicineneurosurgerydiagnosticdelayclonazepam
NSWhospital2023-06-23

Inquest into the death of Baylen Pendergast

21y · Male·Complications of blunt head injury resulting from at least two separate acts of …

Baylen Pendergast, 21 months old, died from complications of blunt head injury sustained in two separate traumatic incidents (17 and 28 November 2013). The coroner found injuries were non-accidental and resulted from sig…

paediatricsemergency medicinediagnosticcommunication
VIChospital2023-05-24

Finding into death of Mr V

73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…

A 73-year-old man presented to ED with acute facial droop and speech difficulty on 5 September 2020. He was misdiagnosed with Bell's palsy despite clinical features suggestive of stroke. A non-contrast CT brain (inadequa…

emergency medicineneurologydiagnosticcommunicationprednisolone
VIChospital2023-04-18

Finding into death of Abdullahi Osman Bashir

27y · Male·Head injury

Abdullahi Bashir, 27, died from a severe head injury sustained during an alleged altercation on 7 June 2017. Following a punch to the face, he fell backwards and struck his head on the road. He was taken to a private res…

neurosurgeryintensive carediagnosticdelaymethamphetamine

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