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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
VIChospital2024-08-06

Finding into death of Noah Andrew Souvatzis

1y · Male·acute meningitis from Streptococcus pneumoniae, associated with diffuse brain sw…

Noah Souvatzis, a 19-month-old boy, died from Streptococcus pneumoniae meningitis on 31 December 2021 after presenting to Northeast Health Wangaratta ED on 29 December. Critical failures in his first ED presentation incl…

emergency medicinepaediatricsdiagnosticproceduralondansetron
VIC2024-07-23

Finding into death of Sarah Catherine Tonkin

37y · Female·Blunt force head injuries

Sarah Tonkin, 37, died when a tow hitch assembly became dislodged from an Isuzu truck and struck her vehicle head-on, causing severe head injuries. The hitch pin securing the tow hitch was not properly installed during t…

proceduralsystem
NSWcommunity2024-07-08

Finding into death of Jesse Lee Christopher EDWARDS

20y · Male·Prone restraint asphyxia in the setting of alcohol intoxication and centripetal …

Jesse Edwards, a 20-year-old Yorta Yorta and Mutthi Mutthi man, died from prone restraint asphyxia following a physical altercation outside a nightclub in Swan Hill. He was restrained face-down by a security officer for …

forensic medicineemergency medicineproceduralalcohol
TAShospital2024-07-03

Coroner's Finding: Wragg, Dennis Edward

95y · Male·Head injuries (subarachnoid haemorrhage, frontal bone fracture and contrecoup) s…

A 95-year-old man admitted to hospital for fluid overload and cellulitis related to heart failure fell in his hospital room on day 11 of admission whilst attempting to walk to the bathroom without his walker or assistanc…

general medicineneurosurgerysystemprocedural
TAS2024-06-27

Coroner's Finding: Corbin, Roger Paul

57y · Male·multiple injuries sustained in helicopter crash

Roger Corbin, a highly skilled and experienced helicopter pilot and instructor, died in a crash during emergency training on 7 November 2017. While instructing student John Osborne in a simulated hydraulic failure landin…

aviation medicineemergency medicineproceduralcommunication
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
QLD2024-06-11

MUHAMMAD, Mahsan

48y · Male·Undetermined; most likely drowning at sea

Mahsan Muhammad, a 48-year-old Indonesian deckhand, fell overboard from a commercial fishing trawler (K-VERN) in rough seas off Queensland on 18 May 2020. He was working on a boom arm 10 metres outboard, attempting to re…

occupational and environmental healthemergency medicineproceduralsystem
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
WAmental health2024-05-17

Inquest into the Death of Richard Anthony BOROS

50y · Male·upper airway obstruction (choking) from tissue paper

Richard Anthony Boros, a 50-year-old man with paranoid schizophrenia, died from upper airway obstruction (asphyxiation) after intentionally swallowing a dense ball of tissue paper while in the mental health assessment un…

psychiatryemergency medicinecommunicationsystemolanzapine
TAScommunity2024-05-13

Coroner's Finding: Wise, Jari Elliott Ernest

27y · Male·Multiple injuries sustained as a pedestrian struck by a motor vehicle; specifica…

Jari Wise, aged 27, died on 29 February 2020 when struck by a vehicle driven by Melissa Oates at Huonville, Tasmania. Mr Wise was intoxicated (BAC 0.220%, THC present), wearing dark clothing, and standing in the centre o…

forensic medicinetrauma surgeryproceduralcommunicationalcohol
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
VICcommunity2024-04-18

Finding into death of Nami Nakao

22y · Female·Multiple injuries in a truck versus cyclist incident

Nami Nakao, a 22-year-old cyclist, died from multiple injuries sustained when a truck driven by Ted Sheather collided with her at St Kilda Junction on 18 March 2020. She was cycling in a dedicated bicycle lane when the t…

procedural
NSWcommunity2024-04-18

Inquest into the death of Baby Q

0y · Female·unascertained

A nine-month-old First Nations child (Baby Q) was killed by her psychotic father in November 2018. The family, transient and homeless, were known to child protection and police in NSW and Queensland with complex mental h…

paediatricspsychiatrysystemcommunication
NSWhospital2024-04-12

Inquest into the death of Everett Carleton

0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …

Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though …

obstetricsneonatologycommunicationprocedural
TAScommunity2024-04-11

Coroner's Finding: SR

58y · Male·drowning

A 58-year-old man died by drowning while hookah diving off the Tasmanian coast. He was using second-hand equipment purchased online that had multiple safety deficiencies: inadequate filtration allowing contaminants and r…

diving medicinehyperbaric medicineequipment selectionprocedural
TAScommunity2024-04-10

Coroner's Finding: AW

57y · Male·cerebral arterial gas embolism (CAGE)

A 57-year-old experienced commercial diver died from cerebral arterial gas embolism (CAGE) while recreational hookah diving near St Helens Island, Tasmania on 24 December 2021. His diving equipment had multiple critical …

diving medicinehyperbaric medicineproceduralsystem
QLD2024-04-05

Non-inquest findings into the death of PJR

68y · Male·Traumatic asphyxia due to entrapment between shipping container wall and semi-tr…

A 68-year-old man with 17 years' experience died from traumatic asphyxia when unloading semi-trailer axles from a shipping container at work. He failed to position the forklift tines to support the axle pack as required …

proceduralsystem
TAS2024-03-26

Coroner's Finding: Knight, Daniel Thomas

43y · Male·Crush injuries (chest and abdominal injuries and chest compression) sustained in…

Daniel Thomas Knight, aged 43, died from crush injuries sustained while attempting to clear a blockage in a wastepaper compactor (model TCU 660) at a printing business. The compactor had never functioned correctly due to…

occupational and environmental healthforensic medicinesystemproceduralantiepileptic drugs
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
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