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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
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
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
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
VIChospital2022-07-26

Finding into death of Susan Mary Royals

74y · Female·Complications of carotid artery injury from central line insertion in the settin…

Susan Royals, a 74-year-old woman with metastatic colon cancer, died from complications of carotid artery injury sustained during central venous catheter (CVC) insertion as part of a Whipple procedure and hemicolectomy. …

anaesthesiasurgeryprocedural
TAShome2022-05-18

Coroner's Finding: Masters, Shane Anthony

40y · Male·Sudden Unexpected Death in Epilepsy (SUDEP) resulting from post-traumatic brain …

Shane Masters died from Sudden Unexpected Death in Epilepsy (SUDEP) 12 years after sustaining a severe traumatic brain injury at work. On 19 May 2008, a hydraulic jack dislodged while repairing a fully loaded truck in a …

neurosurgeryrehabilitation medicinesystemprocedural
TAShome2020-12-17

Coroner's Finding: Mitsakis, Stavros

79y · Male·Displaced cervical vertebral fracture with secondary carotid artery dissection r…

A 79-year-old man suffered a catastrophic fall from a 3.5-metre ladder while performing home maintenance work on his property. He had recovered from a stroke three months prior, which may have affected his cognitive func…

neurosurgeryneurologyproceduralsystem
NSWhospital2020-01-31

Inquest into the death of OS

5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …

A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…

plastic and reconstructive surgeryanaesthesiamedicationproceduralmorphine
NSWhospital2019-12-17

Inquest into the death of Alan BUGDEN and Amaru BESTRIN

Unknown·Alan Bugden: pulmonary thromboembolism after stroke. Amaru Bestrin: combined dru…

Two deaths occurred in hospital toilets due to undetected collapse in publicly accessible facilities. Alan Bugden, 66, suffered a stroke in an ambulatory care centre toilet at Royal North Shore Hospital and remained unde…

emergency medicineneurologysystemcommunicationheroin
TAShospital2019-07-25

Coroner's Finding: Horcicka, Josef Vratislav

89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…

An 89-year-old man with Parkinson's disease fell at home on 16 August 2016, sustaining a cervical spine fracture. Initial CT imaging missed the C5 inferior articular process fracture, reporting only a paraspinal haematom…

orthopaedic surgeryemergency medicinediagnosticproceduralmorphine
QLDaged care2018-06-05

Milward, Paul Joseph

53y · Male·Choking on food bolus in pharynx, with Huntington's disease and coronary atheros…

Paul Joseph Milward, aged 53 with Huntington's disease causing cognitive impairment and swallowing difficulties, died from choking on a bread sandwich while unsupervised in his aged care room. His care plan specified min…

geriatric medicinespeech pathologycommunicationsystemsodium valproate
ACTaged care2018-02-28

AN INQUEST INTO THE DEATH OFEDWARD ROBERT DAVIS

88y · Male·left frontal lobe haemorrhage due to a fall

Mr Edward Davis, an 88-year-old man with epilepsy, stroke, dementia and on anticoagulation therapy, fell onto a Stand-Up Lifter positioned directly in front of him while waiting for a second staff member to operate it. H…

geriatric medicineemergency medicinesystemproceduralblood thinning medications
QLDhospital2017-10-06

Parsons, Ann

59y · Female·Global cerebral oedema due to hypoxic cerebral ischaemia following cardiac arres…

59-year-old woman admitted with newly diagnosed grade 4 glioblastoma underwent surgery 16 days later after delays during consultant's planned leave. Post-operative complications included ischaemic stroke confirmed on ima…

neurosurgeryintensive carediagnosticcommunicationdexamethasone
QLDcommunity2016-12-08

Floyd, Leah Elizabeth

48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…

A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …

neurologypsychiatrycommunicationsystemdiazepam
NSW2016-07-15

Inquest into the death of Sheila Drysdale

75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …

A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…

plastic and reconstructive surgerygeriatric medicinemedicationproceduralaspirin
VIChospital2016-05-19

Finding into death of Josip Dobrovoljski

62y · Male·Global cerebral ischaemia secondary to intra-operative hypotension following the…

A 62-year-old man died from global cerebral ischaemia following intra-operative hypotension after protamine administration during a cardiac ablation procedure. He had suffered a severe hypotensive reaction to protamine 8…

anaesthesiacardiologydocumentationcommunicationprotamine
VIC2015-05-07

Finding into death of Louis Gerard Le Boeuf

24y · Male·unascertained

Louis Gerard Le Boeuf, aged 24, disappeared from the Sunbury Training Centre on 23 November 1977. He had severe epilepsy, intellectual disability, and required full support for daily living including assistance with walk…

psychiatryneurologycommunicationsystem
SAhospital2005-11-15

Coroner's Finding: DAMIANOU Dimitra

79y · Female·cardio-respiratory arrest consequent upon the aspiration of food

A 79-year-old woman with post-stroke dysphagia died from aspiration of food while hospitalised. A speech pathologist prescribed a minced diet after an unsuccessful soft diet trial, but the patient received a soft diet me…

speech pathologyneurologycommunicationsystem
WAmental health2005-09-23

Inquest into the Death of Robert David Abbott

67y · Male·Ligature Compression of the Neck (Hanging)

Robert David Abbott, aged 67, died by hanging in the secure ward of Joondalup Health Campus on 19 December 2003. He had a long history of depression exacerbated by chronic pain from a 2000 motor vehicle accident, and req…

psychiatrygeneral medicineproceduralsystemvenlafaxine
ACTcommunity2005-06-08

Inquest Into The Manner And Cause Of Death Of Jamie Vincent Johnson

20y · Male·diffuse cerebral oedema caused by hyponatraemia caused by excessive self-induced…

Jamie Johnson, 20, was intellectually disabled and lived in supported accommodation with carers. In June 2000, he was admitted with severe hyponatraemia and seizure from excessive water drinking (psychogenic polydipsia).…

neurologypsychiatrycommunicationsystem

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