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VICcommunity2021-11-29

Finding into death of Felicity Ruth Loveday

83y · Female·unascertained

Felicity Ruth Loveday, aged 83, disappeared and is presumed deceased after setting sail from Port Phillip Bay on 11 December 2019 with her son. Ms Loveday had significant medical and cognitive vulnerabilities including s…

general practicegeriatric medicinesystemdelay
NSWprison2021-11-19

Inquest into the death of Danny Whitton

25y · Male·Multiple organ failure due to acute paracetamol poisoning

Danny Whitton, a 25-year-old Aboriginal prisoner at Junee Correctional Centre, died from acute paracetamol toxicity causing multi-organ failure. He presented to the prison medical clinic on 5 November 2015 with vomiting …

emergency medicinetoxicologydiagnosticcommunicationparacetamol
NThome2021-11-09

Inquest into the death of Holly Davidson

38y · Female·Subdural haemorrhage in the context of chronic alcoholism due to post-traumatic …

Holly Anne Davidson, a 38-year-old police officer, died from a subdural haemorrhage sustained 3-5 days before her death. She had been in a coercive, controlling, and violent relationship with her police officer partner f…

emergency medicinepsychiatrydiagnosticsystemparacetamol/codeine/doxylamine
NSWhospital2021-11-09

Inquest into the death of Caitlin CRUZ

3y · Female·complications of Influenza B viral infection

Three-year-old Caitlin Cruz presented to a medical centre unwell and collapsed, requiring resuscitation. She was transferred by ambulance to Children's Hospital at Westmead but critical information about her collapse and…

emergency medicinepaediatricscommunicationdiagnosticmidazolam
NSW2021-11-08

Inquest into the death of Walter CLOUGH

66y · Male·Complications of chronic obstructive pulmonary disease. A significant contributi…

Walter Clough, aged 66, died from complications of COPD and cardiomegaly while incarcerated. He had significant respiratory compromise from prior chest trauma causing hemidiaphragm paralysis. Days before death, he was ho…

general practicerespiratory medicinesystemspriva
SA2021-11-04

Coroner's Finding: Papageorgiou, Theo Nickolas

27y · Male·compression of the neck due to hanging

Theo Papageorgiou, a 27-year-old man with a history of psychotic and manic symptoms since November 2014, was briefly detained under a mental health order in November 2015 but discharged after only six days despite contin…

psychiatrygeneral practicediagnosticcommunicationolanzapine
WAprison2021-11-01

Inquest into the Death of Joseph Thomas ROE

50y · Male·subarachnoid and intracerebral haemorrhage in association with a ruptured berry …

Joseph Thomas Roe, age 50, died from a ruptured berry aneurysm causing subarachnoid and intracerebral haemorrhage. He was a prisoner at Casuarina Prison when he called for medical assistance on the night of 17-18 Septemb…

emergency medicineneurosurgerycommunicationsystem
QLDhospital2021-11-01

Masoumali, Omid

24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns

Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement.…

plastic and reconstructive surgeryintensive carecommunicationsystem
VIChome2021-10-23

Finding into death of Mr C

56y · Male·Ischaemic Heart Disease and Coronary Artery Atherosclerosis

A 56-year-old man with a history of coronary artery disease and stenting presented to his GP on 17 February 2020 with right upper quadrant discomfort. The GP did not consider a cardiac source, attributing symptoms to abd…

general practicecardiologydiagnosticsystem
WAmental health2021-10-22

Inquest into the Death of Russell David BROCKLISS

38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…

Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute car…

psychiatryemergency medicinedelaysystemrisperidone depot
NSW2021-10-21

Findings into the death of P

72y · Male·Hanging

A 72-year-old male inmate at Long Bay Correctional Centre died by hanging in April 2017. He had a documented history of depression managed with antidepressant medications, and his medication (mirtazapine) was adjusted tw…

psychiatrycorrectional healthsystemmirtazapine
VIChome2021-10-12

Finding into death of Mr A

51y · Male·Hanging

A 51-year-old man with mild intellectual disability from childhood head injury died by hanging following family violence separation. He perpetrated physical, emotional and verbal abuse against his wife and children over …

general practicepsychiatrycommunicationdiagnosticvenlafaxine
TAShome2021-10-08

Coroner's Finding: Reaks, Karen Tracey

49y · Female·combined prescription drug intoxication (zopiclone, amitriptyline, periciazine)

Karen Tracey Reaks, aged 49, died from combined prescription drug intoxication involving zopiclone, amitriptyline, and periciazine, with systemic lupus erythematosus as a contributing factor. She ingested medications in …

general practicepsychiatrysystemdelayzopiclone
VIChospital2021-09-27

Finding into death of Abigail Louise Cooke-Mitchell

42y · Female·Traumatic right subdural haematoma

A 42-year-old woman died from a traumatic right subdural haematoma sustained on 22 January 2015. She was found unresponsive at home with severe head and facial injuries after falls. Critical delays in medical assessment …

emergency medicineneurosurgerycommunicationdelaymorphine
NSWcommunity2021-09-23

Inquest into the death of M F

46y · Male·blunt force injuries from motor vehicle collision with a tree

A 46-year-old Aboriginal man died by suicide following a motor vehicle collision with a tree while being pursued by police responding to a welfare check. He had a complex history of depression, amphetamine addiction (ice…

general practicepsychiatrysystemdelayamphetamine
TAS2021-09-17

Coroner's Finding: Infant Deaths

varied: sudden unexpected death in infancy (unsafe sleeping environment); drowni…

Coroner's joint inquest into deaths of seven children (six infants and one child aged 16 years) between 2014 and 2018 in Tasmania. All families had history of Child Safety Services (CSS) involvement. Coroner found no dir…

paediatricspsychiatrydiagnosticcommunicationalcohol
QLDcommunity2021-09-10

Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings

49y · Female and male·Gunshot wound to head inflicted by spouse

Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…

general practicepsychiatrydiagnosticcommunicationcannabis
VIChome2021-09-08

Finding into death of DA

38y · Male·Mixed drug toxicity

DA was a 38-year-old man who died from mixed drug toxicity involving sedating medications and alcohol. He had longstanding severe anxiety and became dependent on codeine and benzodiazepines, initially obtained from multi…

general practicepsychiatrycommunicationsystemcodeine
WAprison2021-09-06

Inquest into the Death of Marshall Ruben EDGILL

38y · Male·combined effects of acute-on-chronic respiratory disease and cardiomegaly

Marshall Ruben Edgill, a 38-year-old Indigenous man, died in custody from acute-on-chronic respiratory disease and cardiomegaly. He had longstanding obstructive sleep apnoea (OSA), obesity, asthma, and hypertension. Crit…

respiratory medicinecardiologydiagnosticdelay
QLD2021-09-02

Batalha, Benjamin John

35y · Male·Not determined

Benjamin Batalha, aged 35, died in custody at Arthur Gorrie Correctional Centre. The exact cause of death could not be determined, though respiratory depression from mixed drug toxicity or fatal arrhythmia were likely. H…

psychiatrycorrectional healthsystemdiazepam
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