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TAShospital2024-11-26

Coroner's Finding: de-identified FG

57y · Male·partially suspended hanging

A 57-year-old man with longstanding alcohol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for orthopaedic injuries sustained from intentional jumping. He …

orthopaedic surgerypsychiatrycommunicationsystemdiazepam
NTcommunity2024-11-25

Inquest into the death of Kumarn Rabuntja, Kumanjayi Haywood, Miss Yunupingu and Ngeygo Ragurrk

Female·Domestic violence homicides: Miss Yunupiŋu—stab wound to chest; Ngeygo Ragurrk—b…

This landmark coronial finding examines four domestic violence deaths of Aboriginal women in the Northern Territory—Miss Yunupiŋu (2018), Ngeygo Ragurrk (2019), Kumarn Rubuntja (2021), and Kumanjayi Haywood (2021)—all ki…

paediatricsemergency medicinediagnosticcommunicationalcohol
VIChospital2024-11-22

Finding into death of RD Z

11y · Male·complications of bowel obstruction in the setting of chronic constipation

RDZ was an 11-year-old Aboriginal boy who died from complications of bowel obstruction secondary to chronic constipation with a fecalith. He had been under paediatric care for years with multiple admissions for bowel was…

gastroenterologypaediatric surgerydiagnosticcommunicationmacrogol
VIChospital2024-11-21

Finding into death of Baby LT

2y · Male·Pneumonia

A 2-month-old Aboriginal infant died of pneumonia on 17 July 2019. Key clinical lessons: (1) Fever in infants <3 months requires careful evaluation per RCH guidelines, including investigations and admission for observati…

paediatricsemergency medicinediagnosticcommunication
QLDhospital2024-11-20

Non-inquest findings into the death of Mr W

82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis

An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …

general medicinegeriatric medicinediagnosticcommunicationendone 2.5mg
TASaged care2024-11-18

Coroner's Finding: Bradburn, Lester Basil

73y · Male·Traumatic head, facial and chest injuries caused by fall down stairs at resident…

A 73-year-old man with Parkinson's disease and recent falls died from traumatic injuries after falling down six stairs while exiting a residential aged care facility at 5:00 AM. He had been admitted only 10 days prior an…

geriatric medicineneurologysystemcommunication
WA2024-11-15

Inquest into the death of Kingsley Dean Garlett

32y · Male·ligature compression of the neck (hanging) in a man with methadone and methylamp…

Kingsley Garlett, aged 32, died by hanging in a maximum security prison cell on 31 July 2022. The evidence indicates his death was an impulsive response to relationship conflict with his partner revealed through prison p…

psychiatrypsychologysystemdelaymethadone
NTcommunity2024-11-15

Inquest into the death of Kumanjayi Jurrah

2y · Male·accidental drowning

A 2-year-old boy drowned at a public pool in a remote Australian community during a childcare centre excursion. Critical clinical and organisational failures contributed: no formal risk assessment was documented for the …

public healthemergency medicineproceduralsystem
WAhospital2024-11-13

Inquest into the death of Chloe Grace Tupper

31y · Female·organ failure due to anorexia nervosa

Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…

psychiatrypaediatricssystemcommunicationmirtazapine
VIChospital2024-11-13

Finding into death of Baby XR

1y · Male·Pneumonia (early-onset, caused by Group B Streptococcus)

Baby XR died at one day old from early-onset pneumonia caused by Group B Streptococcus (GBS) acquired during vaginal delivery. The mother had known GBS colonisation and received intrapartum prophylactic antibiotics as pe…

neonatologyobstetricscommunicationsystembenzylpenicillin
VICcommunity2024-11-13

Finding into death of N A

59y · Male·compression of the neck secondary to hanging

A 59-year-old man with treatment-resistant depression, anxiety, and suicidal ideation died by hanging while on weekend leave from psychiatric care. He had been hospitalised four times in 2021 and was receiving electrocon…

psychiatrypsychologycommunicationsystemvenlafaxine
VIChome2024-11-13

Finding into death of Noeline Michelle Dalzell

49y · Female·stab wound to the neck

Noeline Dalzell, a 49-year-old Aboriginal woman, was fatally stabbed in the neck by her partner James Fairhall on 4 February 2020 after 17 years of escalating family violence. Multiple systems failed to protect her and h…

paediatricscorrectional healthcommunicationsystem
VIC2024-11-12

Finding into death of Master K

2y · Male·Drowning

Master K, a two-year-old, drowned in a hotel pool after falling from a step into the deeper adult pool section. He remained unnoticed underwater for over nine minutes while his mother was distracted by her mobile phone, …

communicationsystemmorphine
VICcommunity2024-11-11

Finding into death of Glykeria Skalistis

70y · Female·drowning (likely), but ultimately undetermined cause

Glykeria Skalistis, aged 70, disappeared on 29-30 August 2019 and is presumed to have drowned at Schnapper Point beach. She had a long history of schizophrenia and depression, managed with antipsychotic and antidepressan…

psychiatryemergency medicinediagnosticcommunicationantidepressants
NT2024-11-08

Inquest into the death of Roger Nowland helicopter crash

65y · Male·Multiple blunt force injuries from helicopter crash

A 65-year-old experienced helicopter pilot crashed during mustering operations near Limbunya Station, NT, resulting in fatal blunt force injuries. The ATSB investigation could not definitively determine the cause, identi…

aviation medicinesystemprocedural
QLDhospital2024-11-08

Non-inquest findings into the death of SD

61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed

A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…

haematologypathologydiagnosticcommunicationprednisolone
NSWhome2024-11-08

Inquiry into the fire at Yankees Gap Road Bemboka

On 15 August 2018, a hazard reduction burn on private property at Yankees Gap Road, Bemboka (NSW) breached containment and spread uncontrolled into national parkland, burning approximately 19,664 hectares, destroying at …

communicationsystem
VIChome2024-11-06

Finding into death of Samantha Joy Fraser

38y · Female·Hanging in the setting of multiple blunt force injuries

Samantha Joy Fraser, a 38-year-old psychologist, was murdered by her estranged husband Adrian Basham in July 2018 despite an active family violence intervention order. The coronial investigation identified systemic failu…

general practicepsychologydiagnosticcommunicationdiazepam
VIC2024-11-06

Finding into death of Gregory George Piperidis

46y · Male·Stab wound of the chest and abdomen

Gregory Piperidis (46) died from a stab wound to the chest during a basement burglary incident on 26 June 2021 at Alfred Hospital, Melbourne. He and his friend were stealing bicycles when confronted by apartment resident…

forensic medicinetrauma surgerysystemmethamphetamine
VIChome2024-11-06

Finding into death of Christopher Patrick Dabadie

43y · Male·Unascertained

Christopher Dabadie, a 43-year-old man with a history of alcohol use disorder and seizures, was found dead at home on 1 December 2021, two days after two presentations to hospital where he was intoxicated and self-discha…

emergency medicinetoxicologysystem5f-cumyl-pinaca

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