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TAS2025-02-05

Coroner's Finding: Explosion, Glenorchy

Explosion caused by ignition and deflagration of acetylene leak from a cylinder …

This coronial finding concerns an explosion caused by improper storage and transportation of an acetylene gas cylinder in a work vehicle. Ryan Rayner was seriously injured when an acetylene cylinder stored on its side in…

proceduralsystem
VIChospital2025-01-28

Finding into death of Dustin Buckley

17y · Male·Gunshot wound to the head

Dustin Buckley, 17, died from a gunshot wound to the head at Royal Melbourne Hospital on 27 August 2017. The incident occurred during target shooting at Cat Track when KD fired a .22 rifle that discharged, striking Dusti…

trauma surgeryemergency medicinesystemproceduralmidazolam
VIChome2025-01-28

Finding into death of Mark Brian Lowther

56y · Male·head injuries

Mark Lowther, a 56-year-old plumber, died from head injuries when a tree he was felling with a chainsaw and excavator struck him. The excavator's Roll Over Protection (ROP) had been removed prior to the incident, contrar…

proceduralsystem
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
NT2025

Inquest into the death of Kumanjayi Walker

19y · Male·gunshot wounds to chest and abdomen

Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man, died from gunshot wounds to his chest and abdomen at Yuendumu Police station on 9 November 2019. This coroner's report focuses on systemic failures in policing, youth…

public healthpsychiatrycommunicationsystem
TAS2024-12-18

Coroner's Finding: Kleijnendorst, Bastiaan

77y · Male·multiple chest injuries

A 77-year-old man died from multiple chest injuries sustained when a Mini Loader he was operating rolled over and crushed him. He had no prior experience with plant machinery and received minimal induction training. The …

systemprocedural
WAcommunity2024-12-02

Inquest into the death of NW

31y · Female·unlawful homicide (manslaughter); specific cause could not be determined due to …

NW, aged 31, was killed by her partner on 9-10 October 2021 in Kununurra, Western Australia. She had a history of domestic violence victimization and had obtained a Family Violence Restraining Order. On the evening of he…

emergency medicineforensic medicinecommunicationsystem
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
NTcommunity2024-11-15

Inquest into the death of Kumanjayi Jurrah

2y · Male·accidental drowning

A 2-year-old boy drowned at a public pool in a remote Australian community during a childcare centre excursion. Critical clinical and organisational failures contributed: no formal risk assessment was documented for the …

public healthemergency medicineproceduralsystem
NT2024-11-08

Inquest into the death of Roger Nowland helicopter crash

65y · Male·Multiple blunt force injuries from helicopter crash

A 65-year-old experienced helicopter pilot crashed during mustering operations near Limbunya Station, NT, resulting in fatal blunt force injuries. The ATSB investigation could not definitively determine the cause, identi…

aviation medicinesystemprocedural
NSWhome2024-11-08

Inquiry into the fire at Yankees Gap Road Bemboka

On 15 August 2018, a hazard reduction burn on private property at Yankees Gap Road, Bemboka (NSW) breached containment and spread uncontrolled into national parkland, burning approximately 19,664 hectares, destroying at …

communicationsystem
TAShospital2024-11-07

Coroner's Finding: Flynn, Christine Joy

68y · Female·haemopericardium resulting from perforation of the pericardial sac during laparo…

Mrs Christine Flynn, aged 68, died from haemopericardium and pericardial tamponade following laparoscopic hiatus hernia repair. A 2mm perforation of the pericardial sac occurred during surgery, likely from mesh tacks pla…

general surgerycardiothoracic surgeryprocedural
TAShome2024-10-29

Coroner's Finding: Bird, Helen Frances

43y · Female·asphyxia due to hanging

Helen Bird, aged 43, was found hanging in her garage in July 2010. While initially ruled suicide, a reopened coronial investigation found the coroner believes she was killed by her husband Mark Bird. Evidence showed Hele…

general practicepsychiatrydiagnosticprocedural
VIChospital2024-10-29

Finding into death of Shane Hughes

40y · Male·Acute hepatic and renal failure in the setting of postoperative haemorrhage foll…

A 40-year-old man with obesity, COPD, diabetes and hypertension died from acute hepatic and renal failure following postoperative haemorrhage after left radical nephrectomy for a 10cm renal cell carcinoma. The surgeon ap…

urologysurgeryproceduraldiagnosticmetaraminol
QLDaged care2024-10-10

Non-inquest findings into the death of Jean Alice Dowson

79y · Female·Chronic obstructive pulmonary disease

Jean Alice Dowson, 79, died in an aged care facility after being commenced on end-of-life medications. She had severe COPD and was frail (29kg). On 10 April 2017, when she deteriorated with respiratory distress, a Clinic…

general practicepalliative caremedicationdiagnosticmorphine
QLDhospital2024-09-20

Non-inquest findings into the death of HK, a five year old boy

5y · Male·Septic shock due to Influenza A infection and bacterial co-infection with Staphy…

A 5-year-old boy died from septic shock complicating influenza A with bacterial co-infection (Staphylococcus aureus or Group A Streptococcus). He presented to the ED on 22 May 2022 with fever, abdominal pain, and vomitin…

emergency medicineinfectious diseasesdiagnosticcommunication
TAShospital2024-09-12

Coroner's Finding: Chapman, Jane Ann

74y · Female·Post-operative exacerbation of delirium and terminal functional deterioration du…

Jane Ann Chapman, 74, presented to hospital with delirium, fever and suspected urinary tract infection. She fell from an Emergency Department trolley bed, sustaining a neck of femur fracture requiring surgery. Post-opera…

emergency medicineorthopaedic surgeryproceduralsystem
ACThospital2024-09-11

Inquest Into The Death Of Baby X

0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…

Baby X, born at Canberra Hospital after a prolonged labour, died at age 2 days from injuries sustained during birth. Two interlinked pathologies contributed to death: hypoxic-ischemic encephalopathy (HIE) from prolonged …

obstetricsneonatologydiagnosticcommunication
NSW2024-09-06

Inquest into the death of Geoffrey Fardell

52y · Male·Neck compression (ligature strangulation)

Geoffrey Fardell, a 52-year-old man with schizophrenia, HIV, and substance abuse history, died from neck compression (strangulation) while in remand custody at Mid North Coast Correctional Centre. He was placed in a cell…

systemprocedural
ACT2024-08-22

Inquest Into The Death Of Luke Anthony Rich

27y · Male·suicide by hanging

Luke Anthony Rich, age 27, died by suicide by hanging in a prison cell in the Alexander Maconochie Centre (ACT) on 1 February 2022, one day after being remanded in custody on domestic violence allegations. The coroner fo…

psychiatrycorrectional healthsystemcommunicationcocaine
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