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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
QLD2025-10-29

Inquest into the death of Selesa Tafaifa

44y · Female·Cardiac arrest in the context of several contributory factors (physical exertion…

Selesa Tafaifa, a 44-year-old woman with Samoan heritage, died in custody at Townsville Women's Correctional Centre on 30 November 2021 during physical restraint by correctional officers, including application of a safet…

forensic medicineemergency medicineproceduralsystemmixtard 30/70 insulin
NSW2025-02-24

Inquest into the death of Alfonso Ceniccola

82y · Male·Ischaemic heart disease due to coronary atherosclerosis with significant contrib…

An 82-year-old man with advanced ischaemic heart disease and emphysema died from myocardial infarction while in custody in the Acute Care Management Unit of a correctional facility. Correctional officers failed to read h…

cardiologycorrectional healthsystemcommunication
NSWhome2024-11-28

Inquest into the death of Michael Peachey

27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…

Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…

emergency medicinepsychiatryproceduralcommunicationdroperidol
QLDaged care2024-08-22

Non-inquest findings into the death of Malcolm Daniel Moriarty

87y · Male·Combined effects of sotalol toxicity on a background of severe valvular and athe…

An 87-year-old man with Alzheimer's disease died in a residential aged care facility after ingesting Sotalol, a cardiac medication not prescribed to him. The medication trolley was left unlocked and accessible despite fa…

geriatric medicinegeneral practicemedicationproceduralsotalol
QLD2024-06-18

Inquest into the deaths of Shiralee Deanne Tilberoo and Vlasta Wylucki

Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…

Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…

cardiologyaddiction medicineproceduralcommunicationdiazepam
VIChospital2024-05-24

Finding into death of Jacob William Kennedy

36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…

Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He was administered multiple s…

psychiatryaddiction medicinemedicationproceduralmethadone
NSWcommunity2024-05-03

Inquest into the death of Keith Titmuss

20y · Male·exertional heat stroke

A 20-year-old professional rugby league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest aerobic fitness of hi…

sports medicineemergency medicinesystemdelaymidazolam
NSWhome2024-03-21

Inquest into the death of Brandon Rich

29y · Male·cardiac arrhythmia triggered by myocardial ischaemia arising from physical exert…

Brandon Rich, a 29-year-old Aboriginal man, died from cardiac arrhythmia triggered by myocardial ischaemia following a police struggle at his home. He had undiagnosed severe coronary artery disease (75-90% narrowing), mo…

cardiologypsychiatrycommunicationsystemmethamphetamine
QLDhospital2023-06-30

Booth, Yvette and Sandy, Adele and George, Shakaya (“RHD Doomadgee Cluster”)

Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…

This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…

cardiologyemergency medicinecommunicationsystempenicillin
VIC2023-06-22

Finding into death of Cherie Virginia Pearl Guest

61y · Female·Diffuse alveolar damage in a woman with restrictive lung disease following catar…

A 61-year-old woman with severe restrictive lung disease, obesity, cardiac failure, and diabetes underwent cataract surgery at a private day surgery centre on 13 August 2018. She was unable to lie flat and became hypoxic…

ophthalmologyanaesthesiadiagnosticcommunicationlidocaine
TAShospital2023-06-13

Coroner's Finding: HN de-identified

83y·cardiac tamponade due to haemopericardium resulting from traumatic parietal peri…

An 83-year-old woman presented to the ED with chest pain and was found to have a pericardial effusion. She underwent an aortic angiogram but critical investigations including echocardiography were not clearly documented.…

emergency medicinecardiologyproceduralsystem
SA2023-05-12

Coroner's Finding: Morrison, Wayne Fella

29y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to out of hospital …

Wayne Fella Morrison, a 29-year-old Aboriginal man with undiagnosed coronary artery disease (70% stenosis of right coronary artery), died following cardiac arrest during his detention at Yatala Labour Prison. After attac…

emergency medicineintensive caresystemdelay
NSWhome2023-04-26

Inquest into the death of AX

70y · Female·Cause of death could not be determined - available evidence does not allow a fin…

A 70-year-old woman died unexpectedly at home in August 2017. Initially certified as hypertensive heart disease without autopsy, the death was later investigated as a potential homicide following allegations by her forme…

forensic medicinecardiologysystemdelaycandesartan
WAhospital2023-04-17

Inquest into the Death of Edward Ivan AFRICH

64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …

Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…

respiratory medicinecardiologycommunicationsystemthiamine
WAprison2023-01-31

Inquest into the Death of Cally GRAHAM

31y · Female·hypoxic ischaemic encephalopathy, bronchopneumonia and myocardial ischaemia comp…

Cally Graham, age 31, died from hypoxic ischaemic encephalopathy, bronchopneumonia and myocardial ischaemia complicating cardiorespiratory arrest associated with probable Takotsubo cardiomyopathy and methylamphetamine ef…

emergency medicineintensive caresystemcommunicationmethamphetamine
SAhospital2022-10-27

Coroner's Finding: Rentoulis Dimitrios

79y · Male·Iatrogenic right ventricular injury complicating drainage of pericardial collect…

A 79-year-old man died from iatrogenic right ventricular injury sustained during attempted drainage of a post-operative pericardial effusion following coronary artery bypass grafting. During a minimally invasive sub-xiph…

cardiothoracic surgeryanaesthesiaproceduralwarfarin
NSWcommunity2022-07-01

Inquest into the death of Mark MURPHY

49y · Male·Global cerebral hypoxia due to cardiac arrest and drowning, with bilateral bronc…

Mark Murphy, an experienced diver with 657 logged dives, died during an occupational diving course when his full face mask became accidentally dislodged underwater, resulting in sudden cold-water exposure. This triggered…

diving medicineemergency medicinesystemcommunication
WAhospital2022-06-08

Inquest into the Death of Salvatore Giovanni OTRANTO

68y · Male·Complications following myocardial infarction and its treatment in a man with mu…

Salvatore Otranto, a 68-year-old prisoner with multiple severe comorbidities including ischaemic heart disease, diabetes, COPD, and chronic kidney disease, died from complications of myocardial infarction and its treatme…

cardiologyintensive careproceduralenoxaparin
NSWhospital2021-11-09

Inquest into the death of Caitlin CRUZ

3y · Female·complications of Influenza B viral infection

Three-year-old Caitlin Cruz presented to a medical centre unwell and collapsed, requiring resuscitation. She was transferred by ambulance to Children's Hospital at Westmead but critical information about her collapse and…

emergency medicinepaediatricscommunicationdiagnosticmidazolam

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