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NT2024-05-30

Inquest into the death of Douglass Maggie

46y · Male·Complications arising from hyperthermia, with alcohol intoxication and underlyin…

A 46-year-old man with epilepsy, hypertension, and COPD died after prolonged exposure to heat in a locked vehicle on a hot day in Darwin. He had been drinking heavily and was left sleeping in the car while companions vis…

emergency medicineparamedicinesystemdelayalcohol
VIChome2024-05-13

Finding into death of Victor Dale Fenech

56y · Male·complications of metastatic colorectal carcinoma

Victor Dale Fenech, a 56-year-old experiencing homelessness, died from complications of metastatic colorectal carcinoma. He made three emergency calls over two days before his death, but ambulances did not attend the fir…

emergency medicineparamedicinecommunicationsystemcocaine
NSWcommunity2024-05-03

Inquest into the death of Keith Titmuss

20y · Male·exertional heat stroke

A 20-year-old professional rugby league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest aerobic fitness of hi…

sports medicineemergency medicinesystemdelaymidazolam
VIChome2024-04-23

Finding into death of Robert Norman Spencer

59y · Male·ischaemic heart disease in the setting of chronic ethanol use

Robert Spencer, 59, called 000 at 4:27 am reporting weakness and inability to mobilise following a fall. He was triaged as Code 3 (non-urgent) and underwent secondary triage call-back attempts without success. An ambulan…

emergency medicineparamedicinesystemdelay
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
NSWhospital2024-01-30

Inquest into the death of Subash Subedi

26y · Male·Not able to be determined - skeletalised remains

Subash Subedi, a 26-year-old international student from Nepal, died in a stormwater drainage system beneath the M2 Motorway between February 2018 and April 2019. He presented to Westmead Hospital ED on 14 February 2018 w…

emergency medicinepsychiatrycommunicationsystemolanzapine
NTcommunity2024

Inquest into the death of Road Death 28 of 2024

61y · Male·Multiple blunt force injuries sustained in motor vehicle versus cyclist collisio…

A 61-year-old experienced cyclist was struck by a Toyota Landcruiser at a Stuart Highway intersection in Darwin at 5:54 am while riding on the road in dark conditions. Multiple factors compromised visibility: a malfuncti…

forensic medicineemergency medicinesystem
WAhospital2023-12-13

Inquest into the Death of Ashleigh Rebecca HUNTER

26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia

Ashleigh Rebecca Hunter, a previously healthy 26-year-old, died from meningococcal septicaemia (W strain) within 3 hours of arriving at Royal Perth Hospital. She presented with severe generalised pain (10/10), tachycardi…

emergency medicineinfectious diseasesdiagnosticsystemMDMA
NSWcommunity2023-11-30

Inquest into the death of Jacob Carr

53y · Male·Gunshot wound to the left thigh with transection of femoral artery and vein; exs…

Jacob Carr died from a gunshot wound to his left thigh sustained during a police operation at his home. He had assaulted his elderly mother, and police responded to a domestic violence call. During confrontation, Mr Carr…

emergency medicineparamedicinesystemdelayalcohol
SAcommunity2023-10-13

Coroner's Finding: Adams, Michael Gerard

62y · Male·cardiac arrest complicating psychotic episode

Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applie…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
VICcommunity2023-09-18

Finding into death of Meeram Bano

2y · Female·Hypoxic ischaemic encephalopathy in the setting of immersion

Meeram Bano, aged 2 years, died from hypoxic ischaemic encephalopathy following immersion in a pond at Footscray Park on 27 December 2021. She was declared dead on 30 December 2021. While under adult supervision at a fam…

intensive careemergency medicinesystemdelaymidazolam
TAShome2023-08-18

Coroner's Finding: Lukacevich, Anton

64y · Male·coronary atherosclerosis with early myocardial infarction

A 64-year-old man suffered acute myocardial infarction at home. His wife called triple-0 at 10:34 am reporting classic cardiac symptoms: sudden sweating, shortness of breath, and shoulder pain. The emergency dispatch sys…

cardiologyemergency medicinesystemcommunication
TAS2023-07-05

Coroner's Finding: Crump, Damian Michael

36y · Male·Mixed prescription drug toxicity (morphine, lignocaine, amiodarone and midazolam…

Damian Crump, aged 36, was an intensive care paramedic with Ambulance Tasmania who died by suicide on 23 December 2016 by deliberately consuming fatal quantities of morphine, lignocaine, amiodarone and midazolam stolen f…

paramedicinepsychiatrysystemdelaymorphine
SAcommunity2023-05-26

Coroner's Finding: Latouche Mazzei, Lucas

5y · Male·acute upper airway obstruction from nectarine stone

Lucas Mazzei, aged 5 years, died on 27 March 2017 from acute upper airway obstruction caused by an uncut nectarine stone. While attending school, he was separated from his class during a science lesson and left watching …

emergency medicinepaediatricscommunicationsystemlamotrigine
TAShospital2023-05-05

Coroner's Finding: Pedler, Anne Helen

71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis

71-year-old woman presented to ED with signs of circulatory failure (hypotension, tachycardia, tachypnoea, hypoxia) and progressive leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pulmonary emb…

emergency medicinecardiologydiagnosticdelaycannabis oil
NSW2023-03-23

Inquest into the death of LT

24y · Male·methylamphetamine toxicity

LT, a 24-year-old male prisoner, died from methylamphetamine toxicity after ingesting multiple drug-filled balloons that ruptured in his stomach. He had received a prison visit from two individuals with prior contraband-…

emergency medicinetoxicologysystemmethamphetamine
VIChospital2023-02-24

Finding into death of Justin Patrick Crome

39y · Male·Injuries sustained in a fall from the Camberwell train station bridge

Justin Crome, a 39-year-old man with delusional disorder and schizophrenia, died by suicide after jumping from a railway bridge on 13 February 2020. He had a history of mental illness since 2016, multiple psychiatric adm…

psychiatryemergency medicinecommunicationdelaypaliperidone
SAhome2022-12-16

Coroner's Finding: Reid, Paul

50y · Male·ischaemic heart disease

Paul Reid, a 50-year-old Aboriginal man with severe ischaemic heart disease and poor medication compliance, died of a cardiac arrhythmia during his arrest by South Australian Police. He was highly intoxicated (BAC 0.25%)…

cardiologyforensic medicinediagnosticsystemalcohol
VIChome2022-10-04

Finding into death of Baby R

3y · Unknown·Unascertained - natural causes; evidence of aspiration pneumonia, hypoxic-ischae…

Baby R, born at 38 weeks gestation to a mother with previous pregnancy losses, was small-for-gestational-age (SGA, 10th centile). The mother was appropriately excluded from the hospital-supported home birth program due t…

obstetricsmidwiferysystemcommunication
VIChospital2022-09-27

Finding into death of Neville Ernest Mills

66y · Male·Ruptured abdominal aortic aneurysm

A 66-year-old man presented to the Emergency Department with left-sided abdominal pain on 14 July 2021. After waiting over 6 hours in a crowded ED with restricted access to treatment spaces, he left without medical asses…

emergency medicinegeneral surgerysystemdelayibuprofen

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