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SAcommunityNew2026-08-28

Coroner's Finding: Spiess, Thomas Wolfram and Byrne, Jacqueline

Unknown·Thomas Wolfram Spiess: head, neck and chest injuries; Jacqueline Byrne: multiple…

On 18 August 2014, a 14-tonne effluent truck lost control on South Eastern Freeway's steep downhill section and struck multiple vehicles at high speed, killing Thomas Spiess (aged 56) and Jacqueline Byrne (aged 41). Spie…

proceduralsystem
VIChomeNew2026-08-26

Finding into death of Judith Margaret Kerr

78y · Female·Multiple organ failure secondary to sepsis and renal failure due to bronchopneum…

A 78-year-old woman with cognitive impairment, depression, and complex care needs fell at home on 11 February 2022. Her sons delayed seeking medical help for 4 days, during which she developed aspiration pneumonia and wa…

emergency medicineintensive carecommunicationsystemmirtazapine
VICcommunityNew2026-08-21

Finding into death of Kristian David Reinertsen

79y · Male·Crush injuries sustained in workplace incident

Kristian Reinertsen, 79, died when a 575-kilogram water tank crushed him while helping to unload it at a customer's property. He was enlisted as an unpaid helper after the original crew became unavailable. The coroner fo…

systemcommunication
VIChospitalNew2026-08-21

Finding into death of Susanne Keating

64y · Female·Presumed massive pulmonary embolus

Mrs Keating, aged 64, presented to University Hospital Geelong ED with a two-day history of shortness of breath and cough, with known history of pulmonary embolism. Attending physicians appropriately considered PE as dif…

emergency medicinegeneral practicedelaysystem
NSWNew2026-08-21

Inquest into the death of Marina Morel

30y · Female·blunt force head, neck and chest injuries

Marina Morel, a 30-year-old French racehorse trackwork rider, died on 12 February 2022 from blunt force head, neck and chest injuries sustained when a horse fell on her during training at Gulgong Turf Club on 8 February …

system
VIChomeNew2026-08-20

Finding into death of Gayle Patricia Carley

77y · Female·Ischaemic heart disease

Gayle Patricia Carley, 77, collapsed unwitnessed at home with acute ischaemic heart disease on 19 October 2023. Ambulance paramedics arrived and initiated emergency treatment, but a MICA paramedic inadvertently administe…

emergency medicineparamedicinemedicationsystemmetaraminol
SAhospitalNew2026-08-19

Coroner's Finding: Mohammadi, Sohaila

47y · Female·head injury

Sohaila Mohammadi (47) was killed in a motor vehicle collision caused by driver Tristan Mourant, who had bilateral retinal dystrophy and was advised by three medical professionals not to drive. However, none of the docto…

ophthalmologygeneral practiceproceduralsystemalcohol
VICcommunityNew2026-08-17

Finding into death of Guy Christian Mason

48y · Male·Pulmonary thromboembolism

Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…

emergency medicinegeneral surgerydiagnosticsystemenoxaparin
NTcommunityNew2026-08-14

Inquest into the death of Road death 57 of 2024

47y · Male·Multiple blunt force injuries to the neck, chest and lower limbs sustained in a …

A 47-year-old male passenger died from multiple blunt force injuries (bilateral pneumothoraces, pulmonary contusions, ruptured spleen, pelvic fractures, cervical spine fracture with spinal cord haemorrhage) from a high-s…

emergency medicineforensic medicinesystemmethamphetamine
SAhospital2026-08-13

Coroner's Finding: Josipovic, Petar

62y · Male·multi-organ failure on a background of aortic regurgitation and ischaemic heart …

A 62-year-old man with aortic regurgitation and coronary artery disease died from multi-organ failure after emergency cardiothoracic surgery. His elective surgery was cancelled twice (14 and 22 Aug 2023) due to prioritiz…

cardiothoracic surgerycardiologycommunicationsystem
SAhome2026-08-12

Coroner's Finding: Sylvia, Kate Marie

32y · Female·cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage

Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. mis…

paramedicinegeneral medicinediagnosticcommunicationoral contraceptive pill
VIC2026-08-12

Finding into death of Gerald Hoekstra

46y · Male·Effects of fire in the setting of a motor vehicle racing incident

On 4 September 2022, Gerald Hoekstra (46) and his navigator Ede Taric (50) died in a fire following a collision during the Rainbow Desert Enduro Off-Road Race in rural Victoria. While competing in their Can-Am buggy, the…

system
TASaged careNew2026-08-10

Coroner's Finding: Cox, Beverley Jane

88y · Female·Cardiac failure secondary to pacemaker failure and pacemaker battery exhaustion

This case involves an 88-year-old woman with a pacemaker who became lost to follow-up after her last clinic visit in May 2019, when no follow-up appointment was arranged. Without systematic tracking between the specialis…

cardiologygeneral practicesystemcommunication
NSW2026-08-07

Inquest into the death of Amanawel Ayai

23y · Male·complications of bowel obstruction by adhesions

A 23-year-old man in lawful custody at Parklea Correctional Centre presented on 7 January 2022 with severe chest pain, abdominal pain, vomiting, and dehydration, with a significant history of previous abdominal surgery a…

correctional healthgeneral practicediagnosticcommunicationmetoclopramide
SAhospital2026-08-06

Coroner's Finding: Burg, Claus Hartmuth

70y · Male·metastatic gastric adenocarcinoma

A 70-year-old man with prior bladder cancer was undergoing routine CT surveillance. Stomach cancer signs were clearly visible on February 2017 and February 2018 CT scans but failed to be detected by consulting radiologis…

radiologyoncologydiagnosticcommunication
WAhome2026-08-04

Inquest into the Death of Paul Shen Vun WONG

40y · Male·Carbon monoxide toxicity

Paul Shen Vun Wong, a 40-year-old man with treatment-resistant schizophrenia and schizoaffective disorder, died from carbon monoxide toxicity at his Rockingham home in April 2023 while subject to a Community Treatment Or…

psychiatrygeneral medicinecommunicationsystemolanzapine
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
VIChospitalNew2026-07-31

Finding into death of K M

Male·unascertained

KM, an adult with mental health conditions (anxiety, depression), opioid dependence, and hepatitis C, presented to Alfred Hospital ED on 20 December 2024 with bilateral lower leg cellulitis. After initial IV antibiotics,…

emergency medicinesystemdelay
VICaged care2026-07-29

Finding into death of Rosemary Elsie Harriet Jacoby

94y · Female·Drug toxicity (baclofen, gabapentin, oxycodone, pregabalin, zolpidem)

A 94-year-old residential aged-care resident died from drug toxicity after receiving another resident's medications. An agency nurse, unfamiliar with the patient and interrupted during medication preparation, failed to p…

general practiceemergency medicinemedicationcommunicationbaclofen
VICaged care2026-07-29

Finding into death of Lynette Patricia McHarry

69y · Female·Exacerbation of chronic obstructive pulmonary disease and ischaemic heart diseas…

Lynette McHarry, aged 69, died on 15 August 2024 at Casey Hospital following complications from a preventable medication error at Mooraleigh Hostel residential aged care facility. On 4 August, she was mistakenly administ…

geriatric medicinegeneral practicemedicationsystemclozapine

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