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VIChome2022-11-15

Finding into death of Claire Perinovic

7y · Female·Multiple stab wounds to the back

Claire Perinovic, aged 7, died from multiple stab wounds inflicted by her mother Katica during a filicide-suicide incident. Katica had been diagnosed with First Episode Psychosis in November 2020 and treated by NorthWest…

psychiatrygeneral practicecommunicationsystemrisperidone
VIChome2022-11-15

Finding into death of Matthew Perinovic

3y · Male·Multiple stab wounds to the back

Matthew Perinovic, aged 3 years, died from multiple stab wounds inflicted by his mother Katica during a first-episode psychosis. Katica had been receiving mental health treatment from NorthWestern Mental Health Service f…

psychiatrygeneral practicecommunicationsystemrisperidone
TAScommunity2022-11-11

Coroner's Finding: UR de-identified

16y · Male·drowning

A 16-year-old male exchange student died from drowning while free-diving at Lighthouse Bay, South Bruny. His foot became entangled in spear gun line after he dove to retrieve his spear, which had become wedged between ro…

communicationsystem
TASaged care2022-11-08

Coroner's Finding: Kerr,Anthony Neville

81y · Male·pneumonia due to traumatic internal bleeding of the chest wall sustained in fall…

An 81-year-old man with Parkinson's disease, dementia, and multiple comorbidities residing in aged care suffered an unwitnessed fall on 6 June 2021, sustaining a right-sided chest wall haematoma. Staff found him at 7:40a…

geriatric medicineemergency medicinedelaysystem
TASaged care2022-11-08

Coroner's Finding: Oates, Janet Patricia

83y · Female·Hospital-acquired pneumonia caused by injuries from fall; frailty and osteoporos…

An 83-year-old woman died from hospital-acquired pneumonia following spinal fractures sustained in a fall from a mobility hoist at an aged care facility. The hoist failed when the spreader bar detached due to a worn and …

geriatric medicineneurosurgerysystemdelay
NSW2022-11-08

Inquest into the death of Andrew Gilbertson

42y · Male·methadone toxicity

Andrew Gilbertson, a 42-year-old man with bipolar disorder and substance use disorder, died from methadone toxicity while in custody at Long Bay Correctional Centre. He was not enrolled in opioid substitution therapy but…

forensic medicinepsychiatrysystemdelaymethadone
NSWhome2022-11-04

Inquest into the death of EW

75y · Female·Plastic bag asphyxia in the setting of blunt force head injury

EW, aged 75, died from asphyxiation in July 2019 after being struck by her husband MW, who then took his own life. EW had advancing dementia and severe mobility limitations, with MW as her sole carer. The coroner found t…

geriatric medicineoccupational therapysystemcommunication
NSWcommunity2022-11-04

Inquest into the disappearance and suspected death of Morgan Rae

30y · Male·Unable to be ascertained

Morgan Rae, a 30-year-old man with chronic pain and recent life stressors, disappeared on 31 January 2020 from the Bundeena area. The coronal finding examines the NSW Police investigation into his disappearance. Critical…

systemcommunication
VIChospital2022-11-03

Finding into death of Sotirios Temopoulos

76y · Male·Chest sepsis in a man with ischaemic heart disease

A 76-year-old man with multiple myeloma and complex medical history died from chest sepsis and myocardial infarction following a medication dispensing error. After discharge from hospital for spinal compression fractures…

pharmacyhaematologymedicationsystemvalsartan
TAShome2022-10-31

Coroner's Finding: Tunks, John Harold

84y · Male·advanced atherosclerotic coronary vascular disease

John Harold Tunks, an 84-year-old man, died of advanced atherosclerotic coronary vascular disease with contributing emphysema from lifelong smoking. He lived alone despite documented cognitive impairment and functional d…

cardiologyvascular surgerysystem
VIChome2022-10-31

Finding into death of Master S

13y · Male·Asthma

Master S was a 13-year-old Aboriginal boy with severe persistent asthma who died at home on 13 November 2019. He was found unresponsive with his nebuliser mask on his face. The coroner accepted that death resulted from a…

respiratory medicineallergy and immunologysystemfluticasone/vilanterol
NSWhospital2022-10-28

Inquest into death of Dane LOCKWOOD

33y · Male·methylamphetamine toxicity; antecedent causes being the physiological effects of…

A 33-year-old man with methamphetamine addiction and possible schizophrenia attended the ED seeking help while acutely intoxicated, psychotic and sleep-deprived. After initially agreeing to medication, he attempted to le…

emergency medicinepsychiatrysystemdelaymethamphetamine
NSW2022-10-28

Inquest into the death of Todd McKenzie

Male·Consequences of police tactical operation involving use of lethal force (specifi…

Todd McKenzie died following a police operation in Taree involving negotiation attempts, deployment of non-lethal options, and ultimately lethal force. This extensive coronial ruling concerns protective orders over polic…

emergency medicinecorrectional healthsystem
VIChome2022-10-27

Finding into death of Elizabeth Judith Robyn Wilms

29y · Female·Assault with blunt force injuries resulting in widespread bruising and traumatic…

Elizabeth Wilms, age 29, died between 1-5 July 2016 from fatal assault while in an abusive intimate relationship with Alexander Freeburn. Freeburn was the subject of an unexecuted NSW parole warrant for 541 days. The war…

forensic medicinetoxicologysystemdelaygamma hydroxybutyrate
TAScommunity2022-10-24

Coroner's Finding: Woldemichael, Nazrawi

19y · Male·unable to be determined

Nazrawi Woldemichael, a 19-year-old with a history of severe mental illness, traumatic brain injury, suicidal ideation, and substance abuse, disappeared on 9 October 2016 from North Hobart. The coroner determined he is d…

psychiatrytrauma surgerycommunicationsystemcannabis
VIChome2022-10-24

Finding into death of Ying Ying Zhou

36y · Female·Stab wound to the neck

Ying Ying Zhou, aged 36, was fatally stabbed in the neck by her husband Wei Hu on 14 September 2019 in a domestic violence homicide-suicide. The death was preceded by escalating family violence including threats, sexual …

general practicepsychiatrycommunicationsystem
NSWcommunity2022-10-21

Inquest into the disappearance and suspected death of Theo Jean Hayez

18y · Male·Unable to determine

Theo Hayez, an 18-year-old Belgian backpacker, disappeared from Byron Bay on 31 May 2019 after being ejected from a nightclub for approaching intoxication. Digital evidence traced his movements via Google location data t…

systemdelay
NSWcommunity2022-10-21

Inquest into the death of Riley Christopher Shortland

8y · Male·multiple injuries sustained when struck by a truck on the M1 Pacific Motorway

Riley Shortland, an 8-year-old with severe autism spectrum disorder, global development delay, and ADHD, died when struck by a truck on the M1 Motorway after escaping from a vehicle during respite care. He removed his se…

occupational therapypsychologydiagnosticcommunication
NSWout-of-home care2022-10-21

Inquest into the death of Alex Raichman

11y · Male·Multiple injuries sustained when struck by train

Alex Raichman, 11, died when struck by a train after absconding from respite care at Civic Disability Services. Alex had autism, intellectual disability, and seizure disorder with documented absconding risk. Civic knew w…

paediatricspsychiatrysystemproceduralaripiprazole
NSWcommunity2022-10-21

Inquest into the death of Rachel Martin

28y · Female·Multiple injuries sustained when struck by a truck on the M1 Pacific Motorway

Rachel Martin, a 28-year-old SNAP support worker and pregnant woman, died attempting to prevent harm to a high-needs child (Riley) during respite care transport. While driving Riley home on the M1 Motorway, Riley exited …

social workpaediatricscommunicationsystem

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