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SAhospital2024-05-22

Coroner's Finding: Kolega, Sime

54y · Male·multi-organ failure and sepsis complicating fulminant pneumonia with empyema (op…

A 54-year-old man died from sepsis and multi-organ failure secondary to fulminant pneumonia with empyema. He presented to his GP on 1 April 2021 with concerning signs including bilateral oedema, fever, and respiratory sy…

general practiceemergency medicinedelaysystemflixotide
VIChome2024-05-20

Finding into death of Gwyn Pugh

63y · Male·Incised injuries to the neck and upper limbs

Gwyn Pugh, a 63-year-old man with longstanding bipolar affective disorder, died by suicide on 26 October 2022. He had been hospitalized for depression in April-May 2022 and received electroconvulsive therapy. Post-discha…

psychiatrygeneral practicecommunicationsystemmirtazapine
NSW2024-05-17

Inquest into the death of Vicki Higgins

48y · Female·Ischaemic bowel; coronary artery disease, diabetes mellitus and Crohn's disease …

Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (with prior colectomy and ileostomy), and coronary artery disease, died from ischaemic bowel on day 17 of incarceration at Junee Correctional Centre du…

general practicegastroenterologydiagnosticcommunicationinsulin
NSW2024-05-17

Inquest into the death of Vicki Higgins

48y · Female·Ischaemic bowel, with contributing conditions of coronary artery disease, diabet…

Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (requiring ileostomy), and coronary artery disease, died from ischaemic bowel while in custody at Junee Correctional Centre on 29 January 2022, only 17…

general practicegastroenterologydiagnosticdelay
SAhospital2024-05-16

Coroner's Finding: Fisher, Lynne Patricia

60y · Female·sepsis due to community acquired pneumonia

Lynne Patricia Fisher, 60, presented to Mount Barker Hospital ED on 26 September 2018 with bilateral community-acquired pneumonia and was discharged after 6.5 hours despite clinical deterioration. She collapsed at home w…

emergency medicinegeneral practicediagnosticdelayamoxicillin/clavulanate
NSWmental health2024-05-16

Inquest into the death of Roger Frederick Schnelle

59y · Male·head injuries

Roger Schnelle, a 59-year-old accountant, died from head injuries sustained through intentional self-harm while involuntarily detained at Nolan House mental health facility in April 2021. He developed sudden onset severe…

psychiatrygeneral practicediagnosticcommunicationsertraline
VICcommunity2024-05-15

Finding into death of Denise Lucina Roberts

63y · Female·Combined features of bronchopneumonia, emphysema and ischaemic heart disease on …

A 63-year-old woman with depression, anxiety, liver cirrhosis, and chronic drug use died from bronchopneumonia, emphysema, and ischaemic heart disease following a prolonged lie on the ground with hypothermia. She missed …

general practiceaddiction medicinecommunicationsystemdiazepam
WA2024-05-08

Inquest into the Death of Michael John BIRD

22y · Male·Multiple injuries from fall from 21st floor balcony

Michael Bird, 22, died by suicide on 17 March 2022, jumping from the 21st floor of his new workplace on his first day as building manager. He had been experiencing auditory hallucinations and paranoid delusions about pol…

general practicepsychiatrycommunicationsystemzolpidem
TAShome2024-04-30

Coroner's Finding: Mason, Geoffrey

38y · Male·gunshot wound to the left side of the neck resulting in basal skull fracture, su…

Geoffrey Russell Mason, aged 38, died from a gunshot wound to the neck fired by Constable Mitchell during a police response to a domestic incident on 17 February 2020 in Tasmania. Mason was intoxicated, had a long histor…

general practiceemergency medicinesystemalcohol
VIChome2024-04-29

Finding into death of Mr A

32y · Male·Neck compression in the setting of hanging

Mr A, a 32-year-old male with a history of family violence perpetration, mental illness (bipolar disorder, schizophrenia, PTSD), substance misuse, and prior suicide attempts, died by hanging on 21-22 November 2020. He wa…

psychiatrygeneral practicecommunicationsystemalcohol
VICcommunity2024-04-23

Finding into death of Carolyn Mary James

3y · Female·Effects of fire deliberately set by mother in motor vehicle

Carolyn James, a 3-year-old girl, died from the effects of fire when her mother deliberately set fire to a motor vehicle in which she, her sister, and mother were sitting. The investigation examined whether services had …

general practicepsychiatrydiagnosticsystem
VIChome2024-04-23

Finding into death of Caroline Anne Willis

69y · Female·Multiple stab wounds

Caroline Willis, aged 69, was fatally stabbed by her son Jamie in May 2018, two hours after he was served with a Family Violence Intervention Order (FVIO). The death was homicidal and occurred within a context of escalat…

psychiatrygeneral practicecommunicationsystemmethamphetamine
VIC2024-04-18

Finding into death of Timothy Michael Funder

74y · Male·Small bowel obstruction due to extensive intra-abdominal adhesions

Timothy Funder, a 74-year-old man with schizophrenia, chronic obstructive pulmonary disease, and previous small bowel obstruction, died from small bowel obstruction due to extensive intra-abdominal adhesions. He presente…

psychiatrygeneral practicediagnosticdelayclozapine
NSWcommunity2024-04-17

Inquest into the death of Michael Murray

44y · Male·Multiple blunt force injuries from fall from height

Michael Murray, aged 44, died following a fall from Landslide Lookout in the Blue Mountains. He had been diagnosed with borderline personality disorder (BPD) and chronic suicidality. His death highlighted critical gaps i…

psychiatrygeneral practicesystemdelaydiazepam
VIChome2024-04-15

Finding into death of Craig Geoffrey Rickard

55y · Male·Hanging

Craig Geoffrey Rickard, aged 55, died by hanging on 15 January 2020, three days after release from custody serving a Community Corrections Order. He had presented to mental health services multiple times in September 201…

psychiatryemergency medicinesystemcommunicationfluoxetine
WAhospital2024-04-04

Inquest into the Death of Karl Frederick Dominic HOLMES

66y · Male·Complications of metastatic lung adenocarcinoma, with terminal palliative care, …

Karl Frederick Dominic Holmes, a 66-year-old prisoner with metastatic lung adenocarcinoma and hepatocellular carcinoma, died from complications of his terminal cancer while serving a 7-year sentence. He received excellen…

oncologypalliative caresystemdelaymorphine
VICaged care2024-03-28

Finding into death of Shirley Hill Jones

85y · Female·Complications of a left ankle fracture (operated)

An 85-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, hypertension, prior stroke) sustained a left ankle fracture requiring surgical repair. A significant delay occurred in removing her pla…

geriatric medicineorthopaedic surgerycommunicationdelayoxycodone
SAhospital2024-03-27

Coroner's Finding: Collins, Jennifer Ann

30y · Female·tricuspid valve bacterial endocarditis

Jennifer Collins, a 30-year-old intravenous methylamphetamine user, died from tricuspid valve bacterial endocarditis on 6 September 2018. She presented to Noarlunga Hospital ED on 20 August 2018 with chest tightness, fev…

emergency medicinecardiologydiagnosticcommunicationmethamphetamine
NSW2024-03-13

Inquest into the death of O A

44y · Male·multiple injuries from fall from cliff

A 44-year-old man with familial Mediterranean fever (FMF) and bipolar affective disorder with drug-induced psychosis died following a fall from a cliff at Vaucluse during a police rescue operation. He had been managing s…

rheumatologyallergy and immunologycommunicationsystemoxycodone
TAShome2024-03-07

Coroner's Finding: Dorothy Jean Atkins

83y · Female·meningitis with sepsis with the likely source of infection being a large and dee…

Dorothy Jean Atkins, aged 83, died on 9 July 2017 from meningitis and sepsis secondary to a large stage 4 sacral decubitus ulcer. Autopsy revealed severe malnutrition (24.5kg, BMI 13), poor hygiene with faecal soiling un…

geriatric medicinepathologydiagnosticcommunicationirbesartan
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