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VIC2023-07-12

Finding into death of Carl Anthony Van Der Kaay

50y · Male·Cardiomegaly and ischaemic coronary artery disease

A 50-year-old man with significant cardiac risk factors (family history of heart disease, prior coronary stent, diabetes, hypertension, hypercholesterolaemia, smoking) collapsed in cardiac arrest on a V/Line train. Despi…

cardiologyemergency medicinesystembisoprolol
WAhospital2023-07-07

Inquest into the Death of Ashlee Jade REINDL

0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…

Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean se…

obstetricsmidwiferydiagnosticcommunicationoxytocin
VIChospital2023-07-06

Finding into death of Michael Alan Holmes

34y · Male·effects of burns

Michael Holmes, 34, died from severe burns sustained when he re-entered a burning house attempting to rescue his son. The fire originated from clothes and towels left drying on a rack in front of an unattended wood heate…

emergency medicinetrauma surgerysystemfentanyl
NSW2023-07-06

Inquest into the death of RRC

26y · Male·hanging, intentionally self-inflicted

A 26-year-old Aboriginal man died by suicide in custody following discharge from a Risk Intervention Team (RIT) management plan on 19 October 2021. He had self-harmed on 17 October, reporting voices telling him to cut hi…

psychiatrycorrectional healthcommunicationdocumentation
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
NSWhome2023-07-05

Inquest into the death of JY

5y · Male·multiple stab wounds

A 5-year-old boy died from multiple stab wounds inflicted by his father during an acute psychotic episode. The father, diagnosed with schizophrenia in 2003, was admitted to Hornsby Hospital in April 2018 following deteri…

psychiatrygeneral practicecommunicationsystemrisperidone
ACTcommunity2023-06-30

In the matter of four deaths by drowning in the Australian Capital TerritoryThe Inquest into the death of Najeebullah RafeeThe Inquest into the death of William Spencer HooleyThe Inquest into the death of Meredith Nancy HooleyThe Inquest into the death of Dinh Ta Nguyen

23y · Male·Drowning

Najeebullah Rafee, a 23-year-old ANU international relations student and Afghan refugee, drowned on 25 October 2020 at Cotter Bend, a promoted ACT river recreation area. A non-swimmer, he attempted to use a small flotati…

emergency medicineintensive caresystemhydroxychloroquine
TAS2023-06-30

Coroner's Finding: Barron Rickie Underwood

61y · Male·hanging, the result of actions undertaken by the deceased alone, voluntarily and…

Rickie Underwood Barron, aged 61, died by hanging in Tasmania's Ron Barwick Minimum Security Prison on 10-11 January 2022. He had been incarcerated since 2019 for sexual offences and received appropriate medical care for…

psychiatrycorrectional healthsystemantidepressant medication
QLDhospital2023-06-30

Booth, Yvette and Sandy, Adele and George, Shakaya (“RHD Doomadgee Cluster”)

Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…

This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…

cardiologyemergency medicinecommunicationsystempenicillin
WAhospital2023-06-29

Inquest into the Death of Child R (Name Subject to Suppression Order)

11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…

Child R, an 11-year-old Aboriginal girl with congenital anorectal anomalies causing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and vomiting. She died 12 ho…

paediatricsemergency medicinediagnosticcommunicationmacrogol
WAhome2023-06-28

Inquest into the Death of Nicholas Arthur CRIPPS

47y · Male·combined acute effects of multiple drugs in obese man with enlarged heart and ar…

Nicholas Cripps, a 47-year-old man with treatment-resistant schizophrenia, substance use disorder, and antisocial personality disorder, died from combined acute effects of multiple drugs (methylamphetamine, quetiapine, p…

psychiatrygeneral practicesystemmethamphetamine
VIChome2023-06-28

Finding into death of Kelvin Maurice Jeffery

96y · Male·Blunt chest trauma from quad bike accident

A 96-year-old man died from blunt chest trauma sustained in a quad bike accident on his rural property. He had declined in health with poor eyesight, kyphosis, and hand tremors, prompting him to stop driving his car. He …

emergency medicineintensive caresystem
TASaged care2023-06-27

Coroner's Finding: Guy, Peter Joseph

82y · Male·hypostatic pneumonia

An 82-year-old man with dementia and multiple comorbidities died of hypostatic pneumonia following complications from a fall at a residential aged care facility. He sustained an L2 compression fracture from an unwitnesse…

geriatric medicineemergency medicinesystemprocedural
VICaged care2023-06-27

Finding into death of Elizabeth Ethel Watson

89y · Female·Complications of fractured neck of femur in the setting of a fall in a woman wit…

An 89-year-old woman with dementia and high falls risk sustained a fall at an aged care facility on 24 August 2019. The enrolled nurse in charge, on her third unsupervised shift, lacked electronic medical record access a…

geriatric medicineemergency medicinediagnosticcommunicationtramadol
QLDhospital2023-06-26

Searle, William Edward

74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …

William Searle, a 74-year-old prisoner, died from aspiration of gastric contents following a Whipple procedure for recurrent ampullary adenoma. The clinical lessons involve recognition of gastroparesis risk in high-risk …

general surgeryintensive carediagnosticcommunicationadrenaline
VIChome2023-06-26

Finding into death of R M

88y · Female·Carbon monoxide toxicity

An 88-year-old woman died from carbon monoxide toxicity in her campervan. She had installed a portable gas-powered fridge (manufactured 1993) in the rear of her van using a makeshift ventilation system through a window. …

systemoxycodone
VIChospital2023-06-25

Finding into death of Peter John Weatherly

63y · Male·Aspiration pneumonia in the setting of functional decline in a man with an intel…

A 63-year-old man with intellectual disability, cerebral palsy, dysphagia, and COPD died from aspiration pneumonia following functional decline. He had a three-month hospital admission with multiple complications includi…

general medicineemergency medicinesystemcommunicationrisperidone
VIChospital2023-06-23

Finding into death of Edis Vytas Brenner

78y · Male·Multiorgan failure consequent upon pulmonary lacerations and haemorrhage sustain…

A 78-year-old man died from multiorgan failure following complications during planned mitral and tricuspid valve surgery. During the initial surgery, a small superficial laceration to the right lower lobe lung occurred, …

cardiothoracic surgeryintensive caresystem
VICcommunity2023-06-23

Finding into death of Amanda Jane Stapledon

58y · Female·Mixed drug toxicity (oxycodone, temazepam, diazepam, oxazepam, citalopram, fluox…

Amanda Jane Stapledon, 58, died from mixed drug toxicity after intentionally taking her life. She was a former councillor and community advocate who became a person of interest in an IBAC anti-corruption investigation (O…

general practicepsychologysystemoxycodone
NSWhospital2023-06-23

Inquest into the death of Baylen Pendergast

21y · Male·Complications of blunt head injury resulting from at least two separate acts of …

Baylen Pendergast, 21 months old, died from complications of blunt head injury sustained in two separate traumatic incidents (17 and 28 November 2013). The coroner found injuries were non-accidental and resulted from sig…

paediatricsemergency medicinediagnosticcommunication

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