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VIChospital2025-03-18

Finding into death of R J

41y · Male·complications of acute ethanol toxicity

Mr RJ, a 41-year-old man with a history of progressive alcohol misuse and mental health conditions (anxiety and depression), died from complications of acute ethanol toxicity following cardiac arrest due to aspiration an…

emergency medicineintensive caresystemalcohol
VICaged care2025-03-14

Finding into death of Maria Grazia Nardiello

90y · Female·Surgical repair of fractured neck of femur sustained in a fall complicated by CO…

Maria Grazia Nardiello, aged 90, died following surgical repair of a fractured neck of femur sustained in a fall at an aged care facility, complicated by COVID-19 infection. She was pushed by another resident with dement…

geriatric medicineorthopaedic surgerysystem
VIChome2025-03-14

Finding into death of Jonathan Mark Townsend

59y · Male·Unascertained

Jonathan Townsend, a 59-year-old Navy veteran with PTSD, alcohol use disorder, and multiple psychiatric comorbidities, died at home on 5 November 2021. The cause of death was unascertained despite autopsy and toxicology.…

trauma surgerypsychiatrycommunicationsystemdiazepam
VIChospital2025-03-12

Finding into death of Robin Albert Banks

90y · Male·Pneumonia complicating injuries sustained in a motor vehicle incident

A 90-year-old man died from pneumonia following injuries sustained in a motor vehicle collision. He had multiple reportable medical conditions including atrial fibrillation, coronary artery disease, chronic kidney diseas…

general medicinegeriatric medicinecommunicationsystemdigoxin
VIChome2025-03-11

Finding into death of Stephen Peter O'Brien

68y · Male·Head injuries

Stephen O'Brien, aged 68, died from head injuries inflicted by his adult son Scott in a family violence incident. Stephen had been the primary carer for Scott, who had untreated mental illness (suspected schizophrenia), …

general practicepsychologysystemcommunication
WA2025-03-10

Inquest into the Death of Ricky-Lee COUND

22y · Male·ligature compression of the neck (hanging)

Ricky-Lee Cound, 22, an Aboriginal man with FASD, died by hanging in his Hakea Prison cell on 25 March 2022. At 4.11pm, Mr Cound called requesting a monitored safe cell to prevent self-harm, demonstrating clear risk perc…

psychologygeneral medicinediagnosticcommunicationaripiprazole
WAhospital2025-03-06

Inquest into the Death of Jalen Hunter NORRIS

23y · Male·Multiple injuries from being struck by train

Jalen Hunter Norris, aged 23, died by suicide when struck by a train on 9 April 2021. He was experiencing paranoid delusions and had recently been arrested for criminal damage and cannabis possession after an incident at…

emergency medicinepsychiatrycommunicationdiagnosticcannabis
NSW2025-03-06

Inquest into the death of Moses Kellie

33y · Male·hanging

Moses Kellie, aged 33, died by hanging at Villawood Immigration Detention Centre in January 2019 after four years in immigration detention. He had schizophrenia, PTSD, and substance dependence, with a prior suicide attem…

psychiatrygeneral practicesystemcommunicationpaliperidone
NSW2025-03-06

Inquest into the death of Leah Jane Porter

50y · Female·hanging

A 50-year-old woman with severe borderline personality disorder and ADHD died by hanging in immigration detention. The coroner found her mental health monitoring and treatment were adequate, though she received only two …

psychiatrygeneral practicecommunicationsystemmethylphenidate
VICmental health2025-03-04

Finding into death of Jamie Alexander Knowles

24y · Male·neck compression secondary to hanging

Jamie Knowles, a 24-year-old with schizophrenia, died by suicide on 24 June 2024 while on an inpatient temporary treatment order at Kerferd Unit mental health service in Victoria. He was granted one hour of unescorted le…

psychiatrygeneral practicesystemcommunicationclozapine
VIChome2025-03-04

Finding into death of Michael James Batten

43y · Male·Complications of valvular heart disease

Michael James Batten, a 43-year-old with intellectual disability and schizophrenia, died from complications of aortic valve stenosis. A transoesophageal echocardiogram in June 2022 demonstrated severe aortic stenosis req…

cardiologycommunicationsystem
NSWhome2025-03-04

Inquest into the death of ML

1y · Female·complications of acute bronchiolitis arising from Respiratory Syncytial Virus (R…

A 17-month-old First Nations child died from acute bronchiolitis due to respiratory syncytial virus (RSV) infection in inadequate accommodation following parental separation from domestic violence services. The coroner i…

paediatricscorrectional healthsystemcommunicationmarijuana
VIChospital2025-03-03

Finding into death of Caroline Anne McCormack

74y · Female·Infective exacerbation of chronic obstructive airways disease in the setting of …

Caroline McCormack, 74, died from infective exacerbation of chronic obstructive airways disease following a medication administration error where pregabalin was erroneously included in her Webster-pak despite being cease…

general practicepalliative caremedicationsystempregabalin
VICaged care2025-03-03

Finding into death of Heather Ash

68y · Female·Terminal palliation in the setting of ischaemic liver and bronchopneumonia

Ms Heather Ash, a 68-year-old woman with intellectual disability, Parkinson's disease, and dementia living in supported disability accommodation, died from terminal palliation in the setting of ischaemic liver and bronch…

general practicegeriatric medicinesystemmorphine
NSWhome2025-03-03

Inquest into the death of Harmony

15y · Female·hanging

Harmony, a 15-year-old girl, died by hanging at a motel on 14 January 2020 in circumstances of longstanding neglect, family violence and school disengagement. The coroner found multiple systemic failures: DCJ closed case…

paediatricspsychiatrysystemdelaycannabis
NSWhospital2025-02-28

Inquest into the death of Heather Winchester

75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…

A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…

gynaecologyanaesthesiacommunicationsystem
NSW2025-02-28

Inquest into the death of Cameron De Vries

20y · Male·Drowning precipitated by a seizure

Cameron De Vries, a 20-year-old man with severe autism spectrum disorder and global developmental delay, died by drowning precipitated by a seizure in a bathtub at a disability support home. He had experienced a seizure …

emergency medicineneurologydiagnosticsystemranitidine
NSWcommunity2025-02-28

Inquest into the death of Alan Green

48y · Male·Multiple traumatic injuries

Alan James Green (Wally), aged 48, died on 14 December 2021 from multiple traumatic injuries sustained in a motorcycle crash while being pursued by NSW Police for failing to stop at a traffic stop. The police decision to…

communicationsystemmethamphetamine
VICmental health2025-02-27

Finding into death of Judith Mary Pollard

73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…

Judith Pollard, a 73-year-old woman with an extensive mental health history, was voluntarily admitted to Shepparton Private Hospital on 1 June 2023 following acute depression and paranoia. Despite her family informing st…

psychiatryemergency medicinesystemcommunicationamitriptyline
VIChospital2025-02-27

Finding into death of Steven John Parlby

73y · Male·Complications of multiple injuries sustained in a motor vehicle incident (car vs…

A 73-year-old man with extensive medical comorbidities including severe biventricular heart failure, COPD, sleep apnoea, and hypertension experienced a medical episode while driving, causing him to cross into oncoming tr…

general practicecardiologysystemcommunicationvalsartan

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