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WA2025-12-17

Inquest into the Death of Jamie Frederick GINN

50y · Male·cocaine toxicity

A 50-year-old male died from cocaine toxicity at Perth Watch House after ingesting a fatal amount of cocaine prior to arrest. Although the cause is clear, the manner of ingestion (before arrest versus after detention) co…

toxicologyforensic medicinesystemsupervisioncocaine
WA2024-09-05

Inquest into the Death of Robert Fredrick PARNELL

29y · Male·butane and propane toxicity from inhalation of canola oil spray propellants

Robert Parnell, aged 29, died from butane and propane toxicity after inhaling propellants from a can of canola oil spray in a prison kitchen toilet. He had a long history of polysubstance use including solvent sniffing d…

forensic medicineemergency medicinesystemsupervisionbutane
WAhome2023-11-10

Inquest into the Death of Child ML (Name Subject to Suppression Order)

7y · Female·Pneumonia complicating a viral respiratory illness with acute combined drug effe…

Child ML, aged 7, died of pneumonia complicating viral respiratory illness with acute combined drug effect. She had severe cerebral palsy with complex care needs including PEJ tube feeding and multiple medications. At th…

paediatricsrespiratory medicinemedicationsystemcodeine
SAcommunity2023-05-26

Coroner's Finding: Latouche Mazzei, Lucas

5y · Male·acute upper airway obstruction from nectarine stone

Lucas Mazzei, aged 5 years, died on 27 March 2017 from acute upper airway obstruction caused by an uncut nectarine stone. While attending school, he was separated from his class during a science lesson and left watching …

emergency medicinepaediatricscommunicationsystemlamotrigine
VICaged care2023-01-16

Finding into death of Heather Amy Robertson

83y · Female·Complications arising from a fall with C2 fracture and neck of femur fracture

An 83-year-old woman with dementia, Alzheimer's disease, and a prior hip fracture sustained injuries from a fall in her aged care facility's dining room. Staff were absent from the dining room for approximately 7 minutes…

geriatric medicineemergency medicinesupervisionsystem
VIC2022-09-09

Finding into death of Gregory Paul Sedgman

42y · Male·Complications post polypharmacy toxicity

Gregory Sedgman, aged 42, died from polypharmacy toxicity after consuming excessive prescription medications at a post-sentence supervision residential facility. He had deliberately accumulated medications despite a seiz…

psychiatrytoxicologymedicationcommunicationoxycodone
WAmental health2022-02-25

Inquest into the Death of Jordan James WILLIAMS

20y · Male·head and neck injuries sustained when struck by train

Jordan James Williams, 20, died after being struck by a train following two absconsions from Kalgoorlie Health Campus mental health unit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Crit…

psychiatryemergency medicinesupervisioncommunicationolanzapine
VIChospital2021-11-30

Finding into death of Eileen Violet Smith

88y · Female·Head injury in a fall due to atrial fibrillation on anti-coagulants

An 88-year-old woman with atrial fibrillation on anticoagulation died from a subdural haemorrhage sustained in a fall at a rehabilitation hospital. She was assisted to the toilet by a single nursing student despite a doc…

rehabilitation medicineneurosurgeryproceduralcommunication
TAScommunity2020-11-05

Coroner's Finding: Marshall, Eric Craig

19y · Male·Chest and abdominal injuries sustained when a forklift rolled over and trapped h…

A 19-year-old farm worker with intellectual disability died when a forklift he was operating rolled over on a gravel laneway, trapping him beneath the roll cage. Mr. Marshall had received informal training in August 2014…

systemsupervision
QLDhome2020-05-06

T and P - Non-inquest findings

Female·Drowning

Two young sisters, aged 4 and 3 years, drowned in a residential swimming pool while unsupervised. Both parents were present in the home but inattentive—the mother was asleep in the bedroom while the father was using his …

paediatricsemergency medicinesupervisionsystem
ACT2020-03-05

Inquest into the death of WAYNE EDWARD VICKERY

45y · Male·Crush injuries to the head caused by a road grader that accidentally ran him ove…

Wayne Edward Vickery, a 45-year-old construction foreman with 12 years' experience, was fatally crushed by a road grader on 12 December 2011 while measuring blade position. He was kneeling and focused through a scope whe…

systemsupervision
SAaged care2020-02-28

Coroner's Finding: NISCO Sophia Alessia

16y · Female·upper airway occlusion due to aspiration of a foreign body (disposable latex glo…

Sophia Nisco, a 16-year-old with severe cerebral palsy and intellectual disability, died from airway obstruction after aspirating a disposable latex glove at a respite care facility. She had documented oral fixation beha…

rehabilitation medicinesupervisionsystem
WA2019-11-14

Inquest into the Death of David Anthony RICE

49y · Male·multiple injuries

A 49-year-old remand prisoner died from multiple injuries after being pinned between a reversing truck and a coolroom wall in the prison industries yard. The deceased voluntarily offered to guide the truck as it reversed…

proceduralsupervisionparacetamol
VIC2019

Finding into death of ANG

5y · Male·Complications of Immersion and Multiple Injuries in the Setting of a Boating Inc…

A 5-year-old boy died from complications of immersion and multiple injuries sustained in a boating incident on Lake Eildon. While wakeboarding, the child was seated in the bow of the vessel when it decelerated. He leaned…

supervision
WAcommunity2018-05-30

Inquest into the Death of Lachlan James MITCHELL

2y · Male·Hypoxic brain injury following immersion (drowning)

Lachlan Mitchell, a 2-year-old with global developmental delay and hypermobility, drowned in a swimming pool at a family day care home on 9 November 2015, suffering fatal hypoxic brain injury. While swimming pools were n…

emergency medicineintensive caresupervisionsystem
WAmental health2017-06-22

Inquest into the Death of Annette SILVER

47y · Female·Multiple injuries from being struck by a train

A 47-year-old woman with major depressive disorder and anxiety died by suicide while an involuntary psychiatric inpatient. She had attempted suicide in November 2014 and was admitted to Bentley Hospital for psychiatric t…

psychiatrypsychologysupervisionsystemcitalopram
QLDhome2016-04-07

Corben, William Chase

4y · Male·Drowning

William Corben, a 4-year-old non-swimmer with documented chlorine reaction, drowned in neighbours' backyard pool on 28 February 2015 after approximately 20-27 minutes without oxygen. Critical factors included: pool gates…

supervisionsystem
NSWcommunity2016-03-15

Inquest into the death of Tommy NGO

19y · Male·ischaemic brain injury after cardiac arrest, brought about by blunt force injuri…

Tommy Ngo, 19, died from ischaemic brain injury following cardiac arrest caused by blunt force neck injuries sustained during Chinese lion dancing training. He was propelled into a steel pole when his partner missed a ju…

emergency medicineintensive caresupervisionsystem
QLD2016-01-19

Adams, Jamie Christopher; Watkins, Gary Robert - Non-inquest findings

Male·Multiple injuries as a result of being struck by a Track Machine in a railway in…

Two Queensland Rail workers died when struck by a track machine while performing railway maintenance at Mindi in December 2007. The Coroner identified multiple contributing factors: defective lighting on the machine, ina…

communicationprocedural
QLDhome2015-12-18

T, a child aged 15 months

1y · Male·Hypoxic ischaemic encephalopathy due to drowning

A 15-month-old child drowned in a partially-filled, unmaintained home swimming pool after the entrance gate was propped open with a length of wood. The child was playing in the yard while his mother's attention was occup…

paediatricsemergency medicinesupervisionsystem

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