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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
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
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
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
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
NSWcommunity2022-02-18

Inquest into the death of SP

36y · Male·hanging

A 36-year-old man died by hanging on 10 July 2018 after leaving his home in Blacktown, NSW. His partner called Triple Zero after 30 minutes, reporting concern for his welfare and that he was acting strangely, restless, a…

emergency medicineparamedicinecommunicationsystem
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
NSW2021-10-29

Inquest into the death of Jesse DRABSCH

31y · Male·Hypoxic brain injury caused by the exogenous administration of insulin, resultin…

Jesse Drabsch, 31, died from hypoglycaemia after self-injecting insulin in a gym bathroom. A competitive bodybuilder using performance and image enhancing drugs (PIEDs), Jesse entered the bathroom at 5:30pm on 16 Novembe…

endocrinologytoxicologysystemproceduralinsulin
TAScommunity2021-06-18

Coroner's Finding: Bryers, Wallace Edgar

61y · Male·Anaphylactic reaction to bee venom

Wallace Edgar Bryers, aged 61, died from anaphylaxis following a bee sting while participating in beekeeping activities at Isis Farm on 5 January 2018. The coroner found Bryers was a worker under the Work Health and Safe…

emergency medicineoccupational and environmental healthproceduralsystemadrenaline/epinephrine
NSW2021-05-12

Inquest into the death of Jack KOKAUA

30y · Male·Malignant ventricular arrhythmia without myocardial infarction, precipitated by …

Jack Kokaua, a 30-year-old with schizophrenia and coronary artery disease, died from malignant ventricular arrhythmia during a police encounter after absconding from hospital. Contributing factors included positional asp…

emergency medicinepsychiatryproceduralcommunicationzuclopenthixol
NTaged care2020-12-18

Inquest into the death of Barbara Francis

78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…

Barbara Francis, a 78-year-old resident with dementia at Pearl Supported Care in the dementia unit (Dinah), was punched by another resident (Mr A) on 4 September 2018 and fell backward onto her right hip, sustaining an o…

geriatric medicineorthopaedic surgerysystemcommunication
VICaged care2020-04-22

Finding into death of Dorothy May Nelson

81y · Female·Complications of choking on a food bolus in a woman with dementia

Dorothy May Nelson, an 81-year-old woman with dementia, died from complications of choking on a food bolus at an aged care facility. She was served diced beef in casserole (approximately 4cm bolus found at autopsy, despi…

geriatric medicinepsychiatrydiagnosticproceduralmorphine
TAShospital2019-10-29

Coroner's Finding: Holmes, Julie Anne

71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision

Julie Anne Holmes, aged 71, died of pneumonia following a cervical spine fracture sustained in a motor vehicle accident that was not diagnosed during her hospital admission. Critical clinical lessons include: (1) paramed…

emergency medicinegeneral surgerydiagnosticprocedural
NSWcommunity2019-10-04

Inquest into the death of Olivia INGLIS

27y · Female·chest injuries

Olivia Inglis, 27, died from chest injuries sustained in a fall whilst competing in the cross country phase of eventing at the 2016 Scone Horse Trials. She successfully negotiated fence 8A but fell at fence 8B. The coron…

emergency medicineparamedicinesystemcommunication
ACThospital2018-11-29

AN INQUEST INTO THE DEATH OFSIAUTO ELIUTA TUNUMAFONO

43y · Female·cardiac arrhythmia (unascertained), probably fatal cardiac dysrhythmia

A 43-year-old woman collapsed at home and was found in cardiac arrest after 20-25 minutes. Ambulance arrived and recognised ventricular fibrillation but failed to defibrillate for approximately 20 minutes, despite protoc…

emergency medicinecardiologyproceduralsystem
ACTcommunity2018-02-27

AN INQUEST INTO THE DEATH OFELFRIEDE ADELE TREMETHICK

85y · Female·acute exacerbation of congestive heart failure, following injuries suffered in a…

Ms Tremethick, an 85-year-old with congestive heart failure, fell at home and suffered a lacerated forearm. Paramedics attended and initially administered methoxyflurane for pain relief. She developed fulminant pulmonary…

emergency medicineparamedicineproceduralcommunicationmethoxyflurane
NSWhospital2016-12-21

Inquest into the death Kyran DAY

0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…

Kyran Day, a 6-month-old boy, presented to Shoalhaven District Memorial Hospital with vomiting and lethargy on 19 October 2013. He was initially assessed and diagnosed with gastroenteritis based on recent rotavirus vacci…

paediatricsemergency medicinediagnosticcommunication
NT2016-03-18

Inquest into the death of Styles Isaac King

30y · Male·traumatic asphyxiation

Styles Isaac King, an Aboriginal man aged 30, died from traumatic asphyxiation following restraint by crowd controllers at a bar in Katherine, Northern Territory. During an altercation, he was held face-down on the floor…

emergency medicineparamedicineproceduralsystemalcohol

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