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VIChospital2023-10-10

Finding into death of Mary Veronica Morrow

68y · Female·Pulmonary embolism due to deep venous thrombosis secondary to fractured left dis…

Mary Morrow, aged 68, died from pulmonary embolism and deep vein thrombosis following a fractured left ankle sustained in Queensland on 23 June 2021. She received appropriate VTE prophylaxis initially (enoxaparin) but th…

emergency medicineorthopaedic surgerycommunicationsystemenoxaparin
VIChome2023-10-10

Finding into death of Abdurrahman Coskun

53y · Male·Neck compression in the circumstances of hanging

A 53-year-old man with sudden-onset major depression died by hanging after being discharged from acute mental health crisis services. He presented with depressive symptoms, suicidal ideation with vague plans, and failed …

psychiatrygeneral practicecommunicationsystemmirtazapine
VIC2023-10-09

Finding into death of Kevin Timothy Patrick Doherty

Male·Head and chest injuries from shotgun wounds

This coronial finding concerns the deaths of Benjamin Ray (49) and Kevin Doherty (50), who were fatally shot by Travis Cashmore on 22 July 2022 near Kirkstall, Victoria. The coroner established that Cashmore intentionall…

communicationsystem
VIChospital2023-10-05

Finding into death of Ruby-Lee Gold

28y · Female·Multiple injuries sustained in a fall from height

Ruby-Lee Gold, a 28-year-old with schizoaffective disorder and polysubstance abuse, died from multiple injuries sustained falling from an overpass after absconding from Sunshine Hospital's emergency department. She was r…

psychiatryemergency medicinesystemdelaydiazepam
ACT2023-10-04

In the matter of three deaths of AFP appointees in the Australian Capital TerritoryInquest into the Death of Richard RobertsInquest into the Death of Samantha BaglinInquest into the Death of Dominic Coleman

Unknown·Self-inflicted gunshot wound; suicide

Three Australian Federal Police (AFP) appointees died by suicide using AFP-issued firearms: Richard Roberts (57, PSO), Samantha Baglin (44), and Dominic Coleman (52, ASO). All three had untreated mental health conditions…

occupational and environmental healthpsychiatrysystemcommunication
TAScommunity2023-10-04

Coroner's Finding: East, Robert William

78y · Male·subdural haematoma

Robert William East, 78, died from a subdural haematoma sustained when his electric wheelchair became uncontrollable on a gravel path in Glenmore Creek Reserve. He had consumed approximately five beers at the Granada Tav…

emergency medicineneurosurgerysystem
NSW2023-10-04

Inquest into the death of Melville Schrader

76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…

A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2…

oncologygastroenterologydiagnosticsystempsyllium
VIChome2023-10-02

Finding into death of Student KCM

29y · Female·hanging

A 29-year-old international medical graduate student from Bangladesh died by hanging in July 2020. She was studying a Master of Public Health at Deakin University but had failed multiple units and was struggling academic…

public healthpsychiatrysystem
VIChome2023-10-02

Finding into death of Student FSB

35y · Male·Multiple injuries sustained in a fall from a height

A 35-year-old international student from Taiwan died by suicide via fall from an 18-storey apartment building. He had prior diagnoses of anxiety disorder, psychotic disorder, and adjustment disorder documented in Taiwan …

psychiatrysystemcommunicationsertraline
VIChome2023-10-02

Finding into death of Student XRG

22y · Male·Neck compression by ligature suspension (hanging)

A 22-year-old international student from India died by hanging at his home in Victoria. He was studying information technology at Monash University after experiencing academic difficulties, having failed multiple subject…

psychiatrypsychologysystem
VIChome2023-10-02

Finding into death of Student AHT

24y · Male·injuries sustained in a fall from a 15th floor apartment

A 24-year-old international student from China died by suicide, falling from the 15th floor of his apartment building. He was socially isolated in Melbourne, withdrew from activities he enjoyed in China, and experienced …

public healthpsychiatrysystem
TAShome2023-10-01

Coroner's Finding: Czerniejewski, Roswitha

66y · Female·aspiration pneumonitis and gangrenous necrosis of both feet

A 66-year-old woman with untreated rheumatoid arthritis, severe lower limb cellulitis with gangrenous necrosis, and a personality disorder died from aspiration pneumonitis. She had progressive immobility, lived on a couc…

general practicerheumatologysystem
NSWhospital2023-09-27

Inquest into the death of John O'Donnell

73y · Male·Complications of metastatic neuroendocrine lung carcinoma

John O'Donnell, aged 73, died in custody from complications of metastatic neuroendocrine lung cancer while hospitalised at Westmead Hospital. The coroner identified two systemic issues during his brief incarceration at S…

oncologypalliative carecommunicationsystemlanreotide
NSWhome2023-09-25

Inquest into the death of Wayne Mullin

64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…

Wayne Mullin, a 64-year-old man with severe eosinophilic asthma, bronchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 September and 20 October 2021. Toxicology revealed oxycodone and diazepam at l…

general practicerespiratory medicinemedicationcommunicationoxycodone
NThome2023-09-22

Inquest into the death of Baby Croker

2y · Female·accidental drowning

A 2-year-old girl drowned in a private backyard pool in Katherine during a social gathering. The gate between the entertaining area and the pool was propped open, allowing free access. Although 13 adults were present, no…

systemcommunication
WAhospital2023-09-21

Inquest into the Death of John Henry WATERFALL

76y · Male·Bronchopneumonia with multiple organ failure in the setting of advanced metastat…

John Henry Waterfall, a 76-year-old prisoner at Acacia Prison, died from bronchopneumonia with multiple organ failure secondary to advanced metastatic prostate cancer. He received generally appropriate medical care durin…

general practiceoncologysystemprocedural
SAhome2023-09-20

Coroner's Finding: Norman, Colin

66y · Male·unascertained (differential diagnosis: chronic alcoholism with alcohol withdrawa…

Colin Norman, a 66-year-old man with significant disability from traumatic brain injury, chronic alcoholism and liver cirrhosis, died at home after failing to receive essential disability support services over a weekend.…

geriatric medicinesystemcommunication
SAmental health2023-09-20

Coroner's Finding: Chessell, David Edward

43y · Male·compression of the neck due to hanging

A 43-year-old male veteran died by hanging in a psychiatric inpatient unit while under a Level 2 Inpatient Treatment Order. He was admitted after a high-lethality suicide attempt involving overdose and carbon monoxide ex…

psychiatryemergency medicinesystemcommunicationmirtazapine
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
VICcommunity2023-09-18

Finding into death of Refan Abdulrhman M Al Moarfeg

3y · Female·Hypoxic ischaemic brain injury due to drowning

A 3-year-old girl died from hypoxic ischaemic brain injury following drowning in a pond at Footscray Park. She exited an unsecured playground gate with an inoperable latch mechanism and accessed an unfenced pond masked b…

systemdelayfentanyl

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