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VIChome2026-03-16

Finding into death of John O'Grady

63y · Male·Effects of fire

A 63-year-old man with bipolar disorder, Crohn's disease, ADHD and HIV died in a residential fire at his apartment. He was found with evidence of unsafe smoking in bed, including numerous cigarette butts throughout his u…

general practicepsychiatrysystemrisperidone
VIChospital2026-03-13

Finding into death of Wayne Ronald Watson

61y · Male·Intracranial haemorrhage and myocardial infarct

A 61-year-old man with extensive cardiac disease collapsed at a supermarket, striking his head and losing consciousness for less than 10 seconds. Paramedics identified STEMI and administered heparin on advice from Austin…

cardiologyemergency medicinediagnosticcommunicationheparin
NSWhome2026-03-10

Inquest into the death of Judith Ingham

89y · Female·Burn wounds and the consequences thereof

Judy Ingham, aged 89, suffered severe burns from excessively hot water while bathing in her apartment on 26 August 2022, dying 26 days later from burn wound complications. A licensed plumber failed to install a required …

proceduralsystem
WA2026-03-09

Inquest into the Death of Russell Graham PENNY

56y · Male·complications of viral hepatitis related advanced-chronic liver disease

Russell Graham Penny, 56, a Noongar man, died from advanced liver disease with hepatocellular carcinoma while in prison custody. With chronic hepatitis C from intravenous drug use, Russell had developed cirrhosis and was…

correctional healthgeneral medicinesystemcommunication
NSW2026-03-06

Inquest into the death of Gregory Merriman

58y · Male·acute myocardial infarction caused by ischaemic heart disease

Gregory Merriman, a 58-year-old Aboriginal man, died from acute myocardial infarction caused by advanced ischaemic heart disease while in custody at Metropolitan Reception and Remand Centre on 27 December 2022. He experi…

cardiologygeneral practicediagnosticcommunicationperindopril
VIChome2026-03-04

Finding into death of Carol Fay Slade

54y · Female·Severe burns sustained in a house fire (palliated)

Carol Fay Slade, a 54-year-old woman with acquired brain injury from a 2003 motorcycle accident and mobility limitations, died from severe burns sustained in a house fire at her public housing property in Shepparton. The…

emergency medicineintensive caresystemmethadone
VIChome2026-03-04

Finding into death of Ashleigh Peter Mills

57y · Male·Smoke inhalation

Ashleigh Peter Mills, aged 57, died from smoke inhalation in a house fire on 31 August 2020. The fire started from a discarded cigarette in an armchair where his housemate had been smoking and drinking. Multiple preventa…

emergency medicineforensic medicinesystemdelay
VIChome2026-03-04

Finding into death of Marko Kelentric

73y · Male·Effects of fire

A 73-year-old man died in a residential fire in rural Victoria. He was found unresponsive in his bedroom and declared deceased after fire rescue and paramedic resuscitation attempts. Autopsy confirmed death from smoke in…

systemamitriptyline
NSWhome2026-03-04

Inquest into the death of BX

29y · Male·Gunshot wound to the head, self-inflicted

BX, aged 29, died from a self-inflicted gunshot wound to the head on 17 July 2023 during a police siege at Bowenfels, NSW. Following a domestic violence incident report, police arrived and BX refused entry, triggering a …

communicationsystem
VIChome2026-03-03

Finding into death of Rosendo Ortiz

70y · Male·Smoke inhalation

A 70-year-old man died from smoke inhalation in a residential fire at his public housing unit. He lived in severe hoarding and squalor, without electricity for over three years following a billing dispute. The fire likel…

systemclonazepam
VIChome2026-03-03

Finding into death of Nigel Raymond Willoughby

74y · Male·Complications of burns sustained in a fire

Nigel Willoughby, 74, died from complications of burns sustained in a house fire on 2 September 2020. The fire was caused by a carelessly discarded cigarette igniting an armchair in the lounge room while he was smoking a…

system
VIChome2026-02-27

Finding into death of Maryam Hamka

36y · Female·Unascertained

Maryam Hamka, 36, was killed by her intimate partner Toby Loughnane on 11 April 2021. The coroner found cause of death unascertained due to skeletal remains. Critical systemic failures included: Victoria Police's risk as…

systemcommunication
NSWaged care2026-02-27

Inquest into the deaths of Dimosthenis Gesios and Maureen McGreevy

Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…

Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed bread dipped in Milo by an inexperienced AIN without adequate supervisio…

speech pathologygeneral practicesystemcommunication
SA2026-02-26

Coroner's Finding: Eckert, Paul Theodore & Eckert, Thomas Sebastian & Bottrill, Alan Leslie & Neave, David Arthur & Ingram, Rodney Jon & Martin, Peter Joseph & Walker, Roger Malcolm & Kent, Victor Reginald

Male·Drowning (with various contributing cardiac and traumatic factors)

Eight people died in four separate boating incidents in South Australian waters between March 2024 and January 2025, all from drowning or drowning-related causes. The coroner found that lifejackets would likely have prev…

system
SAhospital2026-02-26

Coroner's Finding: Taylor, Warren Richard

79y · Male·Urinary tract infection with E coli bacteraemia on a background of ischaemic hyp…

A 79-year-old man with multiple comorbidities attended Whyalla Hospital ED following a fall. Paramedics documented concerning vital signs (tachypnoea, tachycardia, low oxygen saturation, fever) and a history suggestive o…

emergency medicinegeneral practicediagnosticcommunicationtrimethoprim
NSWhospital2026-02-26

Inquest into the death of Jeremy Webb

16y · Male·Anaphylaxis due to mammalian meat allergy after tick bite, causing an acute exac…

Jeremy Webb, 16, died from anaphylaxis due to mammalian meat allergy (tick-induced) which triggered status asthmaticus. He had experienced red meat reactions since age 10 and a severe respiratory event in April 2021 that…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline
TAShospital2026-02-24

Coroner's Finding: Bradley, Steven Basil

65y · Male·Acute on chronic subdural haematoma caused by accidental falls

Steven Basil Bradley, 65, died from acute on chronic subdural haematoma following an unwitnessed fall in hospital. He had metastatic prostate cancer, ischaemic heart disease, and diabetes. On admission for chest sepsis, …

oncologygeneral medicinesystemdelay
QLDcommunity2026-02-24

Non-inquest findings into the death of Pedro Miguel Ventura Enes

54y · Male·Blunt force head injury due to hit by rock while driving

A 54-year-old Portuguese tourist driving a rental car on the Bruce Highway was struck by a rock that penetrated the windscreen while overtaking a heavy vehicle. The rock, approximately 190mm x 160mm, had become lodged be…

neurosurgerytrauma surgerysystem
NSWcommunity2026-02-24

Inquest into the deaths of Jebriel Dandan and Seiffedine Malas

24y · Male·Multiple Traumatic Injuries sustained as a result of motor vehicle crash during …

Two young men aged 24 and 25 died in a motor vehicle crash during a police pursuit on the M4 Motorway. Police conducted a high-speed speed check (up to 232 kph in an 80 kph zone) for approximately 73 seconds without acti…

forensic medicinetoxicologyproceduralcommunicationcocaine
WAhome2026-02-23

Inquest into the Death of Child MML

11y · Male·Bronchopneumonia and small bowel necrosis with perforation, in a boy with multic…

Child MML was an Aboriginal boy born in April 2010 who suffered catastrophic abusive head trauma at eight months old in December 2010, causing severe lifelong neurological impairment including cerebral palsy, uncontrolle…

neurologypaediatricscommunicationsystem
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