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VIChome2024-06-11

Finding into death of Martin Page

39y · Male·most likely suicide; possibly accidental death from untreated epilepsy or natura…

Martin Page, a 39-year-old man with epilepsy, schizophrenia or Asperger's syndrome, severe obsessive-compulsive behaviours, and intellectual disability, disappeared from his family home in October 2006 and has not been l…

psychiatryneurologysystemdelay
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
WAhome2024-05-28

Inquest into the Death of Cameron Anthony FYFE

27y · Male·gunshot injury to the head

A 27-year-old Western Australian police officer with a longstanding history of depression and anxiety took his own life using his police-issued firearm stored at home. He had struggled with mental health since 2017, atte…

occupational and environmental healthpsychiatrysystemcommunicationdesvenlafaxine
VIChospital2024-05-24

Finding into death of Jacob William Kennedy

36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…

Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He was administered multiple s…

psychiatryaddiction medicinemedicationproceduralmethadone
VIChome2024-05-24

Finding into death of L I

16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…

LI, a 16-year-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescrip…

general practicepsychiatrymedicationdiagnosticcodeine
WAhospital2024-05-23

Inquest into the Death of Baby BE (Name Subject to Suppression Order)

0y · Female·brain death complicating head and neck injury

A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult on at least two occasions: once around 6 May 2019 (evidenced b…

paediatricsneonatologydiagnosticcommunicationmethamphetamine
SAhospital2024-05-22

Coroner's Finding: Kolega, Sime

54y · Male·multi-organ failure and sepsis complicating fulminant pneumonia with empyema (op…

A 54-year-old man died from sepsis and multi-organ failure secondary to fulminant pneumonia with empyema. He presented to his GP on 1 April 2021 with concerning signs including bilateral oedema, fever, and respiratory sy…

general practiceemergency medicinedelaysystemflixotide
NSW2024-05-21

Inquest into the death of Mohamed Warwar

35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…

35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues an…

psychiatrycardiologycommunicationdiagnosticamisulpride
QLDcommunity2024-05-20

PHILLIPS, Sharron

20y · Female·Undetermined

This coronial finding concerns the 1986 disappearance and suspected murder of 20-year-old Sharron Phillips. No medical or clinical issues are central to this case. The inquest examined evidence that Raymond Mulvihill, a …

systemdelay
VIChome2024-05-20

Finding into death of Gwyn Pugh

63y · Male·Incised injuries to the neck and upper limbs

Gwyn Pugh, a 63-year-old man with longstanding bipolar affective disorder, died by suicide on 26 October 2022. He had been hospitalized for depression in April-May 2022 and received electroconvulsive therapy. Post-discha…

psychiatrygeneral practicecommunicationsystemmirtazapine
WAmental health2024-05-17

Inquest into the Death of Richard Anthony BOROS

50y · Male·upper airway obstruction (choking) from tissue paper

Richard Anthony Boros, a 50-year-old man with paranoid schizophrenia, died from upper airway obstruction (asphyxiation) after intentionally swallowing a dense ball of tissue paper while in the mental health assessment un…

psychiatryemergency medicinecommunicationsystemolanzapine
NSW2024-05-17

Inquest into the death of Vicki Higgins

48y · Female·Ischaemic bowel; coronary artery disease, diabetes mellitus and Crohn's disease …

Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (with prior colectomy and ileostomy), and coronary artery disease, died from ischaemic bowel on day 17 of incarceration at Junee Correctional Centre du…

general practicegastroenterologydiagnosticcommunicationinsulin
NSW2024-05-17

Inquest into the death of Vicki Higgins

48y · Female·Ischaemic bowel, with contributing conditions of coronary artery disease, diabet…

Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (requiring ileostomy), and coronary artery disease, died from ischaemic bowel while in custody at Junee Correctional Centre on 29 January 2022, only 17…

general practicegastroenterologydiagnosticdelay
SAhospital2024-05-16

Coroner's Finding: Fisher, Lynne Patricia

60y · Female·sepsis due to community acquired pneumonia

Lynne Patricia Fisher, 60, presented to Mount Barker Hospital ED on 26 September 2018 with bilateral community-acquired pneumonia and was discharged after 6.5 hours despite clinical deterioration. She collapsed at home w…

emergency medicinegeneral practicediagnosticdelayamoxicillin/clavulanate
NSWmental health2024-05-16

Inquest into the death of Roger Frederick Schnelle

59y · Male·head injuries

Roger Schnelle, a 59-year-old accountant, died from head injuries sustained through intentional self-harm while involuntarily detained at Nolan House mental health facility in April 2021. He developed sudden onset severe…

psychiatrygeneral practicediagnosticcommunicationsertraline
VICcommunity2024-05-15

Finding into death of Denise Lucina Roberts

63y · Female·Combined features of bronchopneumonia, emphysema and ischaemic heart disease on …

A 63-year-old woman with depression, anxiety, liver cirrhosis, and chronic drug use died from bronchopneumonia, emphysema, and ischaemic heart disease following a prolonged lie on the ground with hypothermia. She missed …

general practiceaddiction medicinecommunicationsystemdiazepam
VIChome2024-05-14

Finding into death of PJQ PJQ

18y · Female·Multidrug toxicity (GHB, amphetamines, benzodiazepines)

PJQ was an 18-year-old in state care who died from multidrug toxicity (GHB, amphetamines, benzodiazepines) after being discharged early from a residential rehabilitation program. She had complex trauma history, PTSD, and…

paediatricspsychiatrysystemdelayGHB
VIC2024-05-14

Finding into death of Brian Richard Pope

40y · Male·compression of the neck due to hanging

Brian Pope, a 40-year-old man with longstanding mental health issues including major depressive disorder, anxiety, learning disability (dyslexia), and substance abuse history, died by suicide in prison 20 days after rema…

psychiatrycorrectional healthcommunicationsystemmirtazapine
QLD2024-05-13

HARVEY, Thompson

33y · Male·Neck compression (hanging)

Thompson James Harvey, aged 33, died by hanging in his cell at Capricornia Correctional Centre on 13 November 2017, four days after remand for serious offences including attempted murder. He had a recent suicide attempt …

psychiatrypsychologycommunicationdiagnosticmorphine
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

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