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ACThome2026-08-03

Inquest into the death of Felipe Esteban Alvarez (No 2)

Male·toxicity caused by a combination of methylamphetamine and morphine

Felipe Esteban Alvarez died on 30 March 2021 from toxicity caused by methylamphetamine and morphine (heroin) ingestion at his unit in Taylor, ACT. He collapsed after self-injecting heroin in the presence of others, inclu…

addiction medicineemergency medicinedelayproceduralheroin
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 Christopher Doughty

67y · Male·Multi-organ failure secondary to acute myocardial infarction secondary to in-ste…

Christopher Doughty, 67, was admitted to Hervey Bay Hospital on 17 September 2021 with a life-threatening gastrointestinal bleed two months after receiving coronary stents. The bleed was likely caused by dual antiplatele…

cardiologyemergency medicinecommunicationproceduralaspirin
WAhome2026-06-29

Inquest into the Death of David William LAVARS

Male·phosphine toxicity in a man with atherosclerotic heart disease

Robert Lavars died on 6 September 2022 after deliberately ingesting aluminium phosphide tablets while under police arrest at his home in Shoalwater. He had serious health conditions including strokes, heart disease, and …

toxicologyparamedicineproceduralcommunicationaluminium phosphide
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
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
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
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
NSWcommunity2026-02-24

Inquest into the deaths of Jebriel Dandan and Seiffedine Malas

24y · Male·Multiple Traumatic Injuries sustained as a result of motor vehicle crash during …

Two young men aged 24 and 25 died in a motor vehicle crash during a police pursuit on the M4 Motorway. Police conducted a high-speed speed check (up to 232 kph in an 80 kph zone) for approximately 73 seconds without acti…

forensic medicinetoxicologyproceduralcommunicationcocaine
NThospital2026-01-09

Inquest into the death of C Guyula

49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …

A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical fa…

anaesthesiasurgeryproceduralmedicationfentanyl
NSW2025-12-08

Inquest into the death of Benjamin Cullen

41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…

Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from P…

neurologyemergency medicinemedicationsystemlevetiracetam
WA2025-11-28

Inquest into the Death of Cleveland Keith DODD

16y · Male·complications of ligature compression of the neck (hanging)

A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…

psychiatrypsychologyproceduralcommunication
TAShospital2025-11-28

Coroner's Finding: Clark, Dennis

83y · Male·Sepsis due to staphylococcus aureus bacteraemia following infection of a left an…

An 83-year-old man with heart and kidney failure died from sepsis caused by MSSA bacteraemia following infection at a peripheral intravenous catheter (PIVC) insertion site. Ambulance paramedics inserted the PIVC 56 hours…

emergency medicinesurgeryproceduralsystem
VIC2025-11-12

Finding into death of Wendy Ann McCabe

40y · Female·hypoxic ischaemic encephalopathy due to ligature compression of the neck

Wendy McCabe, a 40-year-old woman with a history of depression, anxiety, substance use and previous self-harm, died of asphyxiation from ligature compression after fashioning a noose from a standard blanket in her police…

correctional healthemergency medicineproceduralcommunicationmethadone
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
VIChospital2025-10-17

Finding into death of Rachel Frances Piskun

42y · Female·Pneumonia, underlying severe cerebral palsy

Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…

emergency medicinegeneral medicinediagnosticmedicationmorphine
TAS2025-10-07

Coroner's Finding: de-identified AL

16y · Male·Multiple chest, abdominal and pelvic injuries from quad bike crash; specifically…

A 16-year-old male died from massive chest, abdominal and pelvic injuries sustained in a quad bike crash. The quad bike's right rear wheel detached during riding due to incorrect fitting of after-market wheels using wron…

forensic medicineemergency medicineprocedural
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
NSWcommunity2025-09-24

Inquest into the death of Matthew Richard Lothian

37y · Male·self-inflicted gunshot wound to the head and neck

Matthew Lothian, aged 37, died from a self-inflicted gunshot wound to the head and neck on 6 January 2021 in Wollongong. He was on medical escort from custody when he seized the firearm from Correctional Services Officer…

psychiatrycorrectional healthsystemcommunicationmethadone
TAShospital2025-08-29

Coroner's Finding: Scott, Nicholas Aaron

26y · Male·shotgun wound of the chest

Nicholas Aaron Scott, a 26-year-old prisoner with a history of self-harm, escaped from Royal Hobart Hospital on 2 January 2023 while under correctional officer supervision. He had been admitted for ingestion of foreign o…

correctional healthemergency medicineproceduralcommunicationmethamphetamine
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