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VIChospital2026-01-08

Finding into death of Linette Ann Hawkins

80y · Female·Injuries sustained in a motor vehicle collision (driver)

An 80-year-old woman died from injuries sustained in a motor vehicle collision after likely experiencing a seizure or similar medical episode while driving. She had a history of traumatic brain injury from 1972 and a doc…

neurologytrauma surgerycommunicationsystemlevothyroxine
VIChome2026-01-08

Finding into death of L L

34y · Female·Combined drug toxicity (gabapentin, oxycodone, tramadol, diazepam, citalopram, d…

A 34-year-old woman with complex medical history including chronic pain, sleep disorder, anxiety and PTSD died from combined drug toxicity involving gabapentin, oxycodone, tramadol, diazepam, citalopram, desmethylvenlafa…

general practicerespiratory medicinesystemcommunicationgabapentin
WA2026-01-08

Inquest into the Death of Lewis Walter WARD

Male·out-of-hospital cardiac arrest due to atherosclerotic cardiovascular disease and…

Lewis Walter Ward, a Ngarinyin man in his early thirties, died from out-of-hospital cardiac arrest while playing sport at West Kimberley Regional Prison. He had Type 2 diabetes, hypertension, dyslipidaemia, and was a smo…

cardiologyemergency medicinediagnosticsystem
TAShome2026-01-07

Coroner's Finding: de-identified UN

43y · Male·hypoxic brain injury caused by cardiac arrest due to unintentional drug poisonin…

A 43-year-old man with long-standing opioid use disorder and polysubstance dependence died from hypoxic brain injury following cardiac arrest caused by drug poisoning. He had been prescribed large quantities of pregabali…

general practiceemergency medicinemedicationdiagnosticmethadone
VIChome2026-01-06

Finding into death of Michelle Margaret Darragh

32y · Female·Stab wound to the back extending into the posterior neck, causing subtotal trans…

Michelle Darragh, a 32-year-old social worker, was fatally stabbed by her former partner Benjamin Coman on 9 October 2021. She was pregnant with their third child. The relationship involved progressive coercive control, …

psychiatryemergency medicinediagnosticcommunicationsertraline
WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…

psychiatryintensive caresystemdelayaripiprazole depot
NThospital2025-12-19

Inquest into the death of T. Ptjara and T. Ptjara

Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…

Two Aboriginal brothers with chronic alcohol use disorder and cognitive impairment died in July and September 2023 in Alice Springs Hospital. Both had adult guardianship orders, NDIS packages, and aged care assessments r…

emergency medicineintensive carecommunicationsystem
VIChome2025-12-19

Finding into death of Narisha Faye Cash

41y · Female·Combined Drug Toxicity (ethanol and benzodiazepine)

Narisha Faye Cash, 41-year-old Aboriginal woman, died on 26 March 2020 from combined drug toxicity (ethanol and benzodiazepines) following an inadequate emergency services response to her mental health crisis. She called…

emergency medicinepsychiatrysystemcommunicationalcohol
NSWhospital2025-12-19

Inquest into the death of JBO

27y · Female·Cardiac arrhythmia (first confirmed as ventricular fibrillation) of unascertaine…

A 27-year-old Aboriginal woman suffered sudden cardiac arrhythmia (ventricular fibrillation) immediately after recording video evidence of a suspected breach of her protective apprehended personal violence order (APVO). …

emergency medicinecardiologycommunicationsystemamiodarone
VIC2025-12-18

Finding into death of Chao Liang Mai

56y · Male·Hanging

Chao Liang Mai, a 56-year-old remanded prisoner with documented psychiatric history and previous suicide/self-harm risk flags, died by hanging in a prison cell on 27 November 2018. Critical systemic failures included: (1…

psychiatryemergency medicinesystemcommunication
NSWhome2025-12-17

Inquest into the death of MQ

55y · Female·acute necrotising bronchopneumonia

MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…

general practiceemergency medicinediagnosticdelay
TAShospital2025-12-09

Coroner's Finding: de-identified EM

76y · Female·sepsis as a result of myocarditis and tricuspid valve endocarditis (infective en…

A 76-year-old woman with vascular dementia and emphysema was admitted with sepsis of unknown origin, treated with antibiotics, and discharged after 12 days with improving symptoms. She re-presented 14 days later with rec…

emergency medicinecardiologydiagnosticcommunicationantibiotics
NSWhospital2025-12-08

Inquest into the death of Katrina McGrady

43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm

Trina McGrady, a 43-year-old Goomeroi woman, died from subarachnoid haemorrhage due to a ruptured berry aneurysm on 15 September 2020. She had been admitted to John Hunter Hospital following incidental discovery of two l…

neurosurgeryradiologycommunicationdiagnosticaspirin
NSW2025-12-08

Inquest into the death of Benjamin Cullen

41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…

Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from P…

neurologyemergency medicinemedicationsystemlevetiracetam
QLDhospital2025-12-04

Inquest into the death of Dylan James Bell

28y · Male·Hanging

Dylan Bell, 28, died by hanging following discharge from Redland Hospital ED where he presented with acute psychosis, suicidal and homicidal ideation, and made three self-harm attempts by strangulation. Despite a concern…

psychiatryemergency medicinediagnosticcommunicationLSD
TAScommunity2025-12-03

Coroner's Finding: de-identified JI

54y · Male·Global hypoxic brain injury, cardiac arrest and blunt trauma to cervical spine

JI, a 54-year-old man with chronic schizophrenia, died from global hypoxic brain injury, cardiac arrest and cervical spine trauma following a fall onto a metal grate during an altercation with another resident at support…

psychiatrygeneral practicesystemdiazepam
TAShospital2025-11-28

Coroner's Finding: Clark, Dennis

83y · Male·Sepsis due to staphylococcus aureus bacteraemia following infection of a left an…

An 83-year-old man with heart and kidney failure died from sepsis caused by MSSA bacteraemia following infection at a peripheral intravenous catheter (PIVC) insertion site. Ambulance paramedics inserted the PIVC 56 hours…

emergency medicinesurgeryproceduralsystem
WA2025-11-28

Inquest into the Death of Cleveland Keith DODD

16y · Male·complications of ligature compression of the neck (hanging)

A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…

psychiatrypsychologyproceduralcommunication
WAhospital2025-11-27

Inquest into the Death of Stephen Joseph SCHIPP

58y · Male·complications of oesophageal cancer, with terminal palliative care

Stephen Joseph Schipp, a 58-year-old sentenced prisoner, died from complications of oesophageal cancer with terminal palliative care at Bunbury Regional Hospital. He had been diagnosed with oesophageal carcinoma in Janua…

oncologypalliative caresystemdelaychemotherapy
VIChome2025-11-24

Finding into death of Suk Ching Annie Ng

64y · Female·Blunt Force Trauma to the Head in the Setting of Prolonged Lie; Metastatic Breas…

Annie Ng, aged 64, died from blunt force head trauma sustained in her home on 27 February 2024, with death occurring 9 March 2024 at Royal Melbourne Hospital. Her husband Chai, experiencing severe financial and psycholog…

oncologygeneral practicesystem
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