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VIC2025-05-29

Finding into death of Sharon O'Neill

65y · Female·Head and neck injuries sustained in a motor scooter incident

Sharon O'Neill, a 65-year-old novice rider, died from head and neck injuries sustained during a motorcycle training course at HART in Somerton, Victoria. While practicing acceleration and turning drills on an unfamiliar …

systemtemazepam
NSWhospital2025-05-28

Inquest into the Death of Garry Small

71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …

A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…

emergency medicinegeriatric medicinemedicationdelayceftriaxone
NThospital2025-05-27

Inquest into the death of Child MS

4y · Male·Haemophilus influenzae septicaemia with superimposed respiratory tract infection

A 4-year-old previously healthy male presented to Katherine Regional Hospital on 10 September 2023 with fever and eye pain. He was examined, found to have tachycardia (HR 156) and fever (39.2°C), and diagnosed with viral…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
TASaged care2025-05-26

Coroner's Finding: de-identified GJ

94y · Male·aspiration pneumonia due to stroke following surgery to repair fracture of neck …

A 94-year-old man with dementia died from aspiration pneumonia following a stroke after hip surgery. The stroke and hip fracture resulted from being pushed by another resident with Alzheimer's dementia at an aged care fa…

geriatric medicineorthopaedic surgerysystemdelayoxazepam
VIChospitalPodcast2025-05-26

Finding into death of Nancy Doreen Hay

99y · Female·Chest injuries in the setting of a tram incident (pedestrian)

A 99-year-old woman with dementia and reduced mobility was struck by a tram while crossing at a roundabout intersection in Essendon, Victoria. She sustained severe chest injuries including bilateral pneumothoraces, haemo…

emergency medicinetrauma surgerysystem
VIChome2025-05-23

Finding into death of Shirley Annette Kidd

67y · Female·Head injuries

Shirley Kidd, aged 67, died from head injuries inflicted by her grandson Hayden during a cannabis-induced psychosis. Hayden had experienced severe childhood abuse by his stepfather and subsequently developed mental healt…

psychiatrygeneral practicesystemcannabis
VICaged care2025-05-22

Finding into death of Veronica Lesley Roberts

75y · Female·Ischaemic heart disease in the setting of unstable type 2 diabetes mellitus and …

Veronica Roberts, 75, died from ischaemic heart disease complicated by unstable diabetes and a medication error. On 4 October 2020, her insulin dose was increased to 20 units daily, but due to Electronic Medical Record (…

geriatric medicinegeneral medicinemedicationsystemglargine insulin
VIChospital2025-05-21

Finding into death of Nazlou (Helen) Danilidis

94y · Female·Complications of a fractured neck of femur sustained in an unwitnessed in-hospit…

A 94-year-old woman with significant cardiopulmonary comorbidities died from complications of a fractured femur sustained in an unwitnessed hospital fall. Despite identification as high falls risk and implementation of f…

geriatric medicinecardiologysystemcommunicationlorazepam
VIChome2025-05-21

Finding into death of Phillip Henry Reidy

27y · Male·Cyanide toxicity

Phillip Reidy, 27, died from cyanide toxicity after ingesting sodium cyanide during police arrest for a family violence incident. He had purchased 250g of sodium cyanide online from Bacto Laboratories using false informa…

forensic medicineemergency medicinecommunicationsystemsodium cyanide
VICaged care2025-05-21

Finding into death of Lorraine Joy Wight

77y · Female·Airways obstruction by tissue paper

A 77-year-old woman with depression, anxiety, and chronic pain died from airway obstruction by tissue paper at an aged care facility. She had expressed suicidal ideation, attempted self-harm, and was found with tissues i…

geriatric medicinepsychiatrycommunicationsystemoxycodone
SAcommunity2025-05-20

Coroner's Finding: Raines, Edward John

86y · Male·multiple injuries from motor vehicle collision

An 86-year-old man died in a head-on motor vehicle collision after driving unsafely on a highway. Three weeks prior, police observed him driving dangerously, unable to judge distances or perceive traffic, and submitted a…

systemdelay
SA2025-05-20

Coroner's Finding: Pham, Duy Ngoc

35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…

35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…

emergency medicinegeneral practicedelaycommunicationmethamphetamine
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…

emergency medicineintensive carediagnosticproceduralhydromorphone
VIChome2025-05-20

Finding into death of CDE

33y · Female·Sharp force neck and chest injuries

A 33-year-old woman was fatally assaulted by her intimate partner in July 2019 following a two-year relationship marked by documented family violence and his untreated mental health conditions. The perpetrator had a hist…

psychiatryemergency medicinesystemcommunicationsynthetic marijuana
VIC2025-05-20

Finding into death of Jessica Anne Katgert

41y · Female·Cardiomegaly

Jessica Katgert, aged 41, died in custody at Dame Phyllis Frost Centre from cardiomegaly. She had a history of MSSA infective endocarditis treated in 2021 with echocardiographic changes including dilated left ventricle a…

cardiologyinfectious diseasessystembuprenorphine
VICmental health2025-05-19

Finding into death of Anna Lee

70y · Female·Asphyxia due to airway obstruction

Anna Lee, a 70-year-old retired psychiatric nurse, died from asphyxia due to airway obstruction while an inpatient in a mental health unit. She was admitted with first-episode mania with psychotic features, triggered by …

psychiatrygeriatric medicinesystemolanzapine
NSWcommunityPodcast2025-05-16

Inquest into the death of Harri Tapani Jokinen

56y · Male·Multiple injuries sustained in a motor vehicle collision

Harri Jokinen, aged 56, died following a head-on motor vehicle collision on the Monaro Highway when a stolen Commodore being pursued by NSW police crossed into his lane. Clinical lessons: This was a non-medical death but…

systemcommunicationalcohol
VIC2025-05-14

Finding into death of Harold Edward Burgess

89y · Male·unascertained - natural causes

Harold Edward Burgess, aged 89, died in Port Phillip Prison's medical unit from unascertained natural causes following a fall on 6 November 2022 that resulted in cervical spine fractures. He was deemed unsuitable for sur…

neurosurgerycorrectional healthsystem
VIChospital2025-05-13

Finding into death of Baby W

0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour

Baby W died within 40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision…

obstetricsneonatologydiagnosticproceduralclindamycin
VIC2025-05-12

Finding into death of Aileen Mary McLeish

54y · Female·Pulmonary thromboembolism complicating left calf deep venous thrombosis in the s…

54-year-old woman with frontotemporal dementia and Parkinson's disease died from pulmonary thromboembolism complicating deep venous thrombosis. She fell during the night at a disability accommodation facility and was fou…

geriatric medicineemergency medicinecommunicationsystemnordiazepam

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