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NSWhospital2024-05-10

Inquest into the death of Finlay Browne

16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…

Finlay Browne, a 16-year-old with Down syndrome, presented to Bathurst Base Hospital on 30 September 2016 with acute abdominal pain and vomiting. Despite clear clinical signs—including a lactate of 7.2 mmol/L (grossly ab…

emergency medicinesurgerydiagnosticcommunication
WA2024-05-08

Inquest into the Death of Michael John BIRD

22y · Male·Multiple injuries from fall from 21st floor balcony

Michael Bird, 22, died by suicide on 17 March 2022, jumping from the 21st floor of his new workplace on his first day as building manager. He had been experiencing auditory hallucinations and paranoid delusions about pol…

general practicepsychiatrycommunicationsystemzolpidem
WAhospital2024-05-06

Inquest into the Death of Devan Beau GINBEY

20y · Male·Hypoxic brain injury following ligature compression of the neck (hanging)

Devan Ginbey, a 20-year-old with longstanding mental health issues including depression, psychosis, ADHD, and substance abuse, presented to Peel ED on 12 January 2022 with self-harm and active suicidal ideation with a st…

emergency medicinepsychiatrysystemdelay
VIChospital2024-05-06

Finding into death of Errol Leslie Solly

67y · Male·Ischaemic heart disease; coronary artery atherosclerosis (stented)

A 67-year-old man with extensive cardiac history presented to the ED with recurrent ischaemic-sounding chest pain. Despite multiple episodes of chest pain during admission, initial ECGs and troponins were normal. Followi…

emergency medicinecardiologydiagnosticcommunicationmorphine
VICcommunity2024-05-03

Finding into death of KLH KLH

66y · Female·Multiple injuries sustained in a tram incident (pedestrian)

A 66-year-old woman was struck by a tram after stepping into its path at a pedestrian crossing adjacent to tram stop 117 in South Melbourne. The tram driver was travelling at approximately 30 km/h and applied full brakes…

system
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
TAShome2024-04-30

Coroner's Finding: Mason, Geoffrey

38y · Male·gunshot wound to the left side of the neck resulting in basal skull fracture, su…

Geoffrey Russell Mason, aged 38, died from a gunshot wound to the neck fired by Constable Mitchell during a police response to a domestic incident on 17 February 2020 in Tasmania. Mason was intoxicated, had a long histor…

general practiceemergency medicinesystemalcohol
QLD2024-04-30

WILLIAMS, Russell James

51y · Male·Incised wound to the right arm

Russell Williams, aged 51, died by suicide in a Queensland prison on 15 May 2018 by cutting his right arm with a disposable razor blade. He was remanded on two historical murder charges and had spent 15 years in prison o…

psychiatrypsychologydiagnosticsystem
VICaged care2024-04-30

Finding into death of Jean Meyer

96y · Female·complications following a fractured distal right femur

A 96-year-old woman died from complications of a hip fracture sustained when pushed by a fellow resident with severe dementia at an aged care facility. The resident pressed the call bell for help, but the system was non-…

geriatric medicineorthopaedic surgerysystem
VIChome2024-04-29

Finding into death of Mr A

32y · Male·Neck compression in the setting of hanging

Mr A, a 32-year-old male with a history of family violence perpetration, mental illness (bipolar disorder, schizophrenia, PTSD), substance misuse, and prior suicide attempts, died by hanging on 21-22 November 2020. He wa…

psychiatrygeneral practicecommunicationsystemalcohol
VICmental health2024-04-26

Finding into death of Allison Leah Randall

37y · Female·Hanging

Allison Randall, a 37-year-old woman with a history of anxiety, depression, and childhood trauma, was admitted to the Northern Hospital psychiatric unit on 15 May 2020 following acute concerns about her partner's behavio…

psychiatrysystemdiazepam
VIChome2024-04-23

Finding into death of Evlyn Kay James

6y · Female·Effects of fire

Evlyn James, aged 6 years, died from effects of fire deliberately set by her mother in a parked motor vehicle on 24 March 2022. Her mother Jasmine Thomas was experiencing significant relationship stress, depression, and …

systemcommunication
VICcommunity2024-04-23

Finding into death of Carolyn Mary James

3y · Female·Effects of fire deliberately set by mother in motor vehicle

Carolyn James, a 3-year-old girl, died from the effects of fire when her mother deliberately set fire to a motor vehicle in which she, her sister, and mother were sitting. The investigation examined whether services had …

general practicepsychiatrydiagnosticsystem
VIChome2024-04-23

Finding into death of Caroline Anne Willis

69y · Female·Multiple stab wounds

Caroline Willis, aged 69, was fatally stabbed by her son Jamie in May 2018, two hours after he was served with a Family Violence Intervention Order (FVIO). The death was homicidal and occurred within a context of escalat…

psychiatrygeneral practicecommunicationsystemmethamphetamine
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
NSWcommunity2024-04-23

Inquests into the deaths of Mona Lisa and Jacinta Smith

Female·Mona: multiple internal injuries (including head and lung injuries) sustained in…

Mona Lisa Smith (16) and Jacinta 'Cindy' Rose Smith (15), Aboriginal girls from Bourke, NSW, died in a single-vehicle motor vehicle accident on 6 December 1987 when a Toyota utility driven by Alexander Grant rolled over …

forensic medicinediagnosticsystemalcohol
QLDhospital2024-04-22

Non-inquest findings into the death of Lenore

48y · Female·Hypoxic ischaemic encephalopathy due to pulmonary thromboembolism due to deep ve…

A 48-year-old woman with morbid obesity and smoking history presented to a rural hospital with severe hip and leg pain. Over five days across two hospitals, no venous thromboembolism (VTE) risk assessment was performed d…

emergency medicineorthopaedic surgerydiagnosticsystemoxycodone
TASprison2024-04-18

Coroner's Finding: Gerard, Robert Harold

48y · Male·Hanging (partially suspended hanging using shoelaces as ligature)

Robert Harold Gerard, aged 48, died by hanging in Risdon Prison in May 2022 while on remand for serious charges. He had paranoid schizophrenia, a long history of substance abuse, and was experiencing depression and suici…

psychiatrycorrectional healthsystemdelayzuclopenthixol decanoate
VIC2024-04-18

Finding into death of Timothy Michael Funder

74y · Male·Small bowel obstruction due to extensive intra-abdominal adhesions

Timothy Funder, a 74-year-old man with schizophrenia, chronic obstructive pulmonary disease, and previous small bowel obstruction, died from small bowel obstruction due to extensive intra-abdominal adhesions. He presente…

psychiatrygeneral practicediagnosticdelayclozapine
NSWcommunity2024-04-18

Inquest into the death of Baby Q

0y · Female·unascertained

A nine-month-old First Nations child (Baby Q) was killed by her psychotic father in November 2018. The family, transient and homeless, were known to child protection and police in NSW and Queensland with complex mental h…

paediatricspsychiatrysystemcommunication

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