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VIChome2022-07-08

Finding into death of X RR

29y · Male·Mixed drug toxicity (heroin and methamphetamine)

A 29-year-old man with a history of heroin and methamphetamine addiction died from mixed drug toxicity. He had suffered a work-related back injury leading to opioid dependence, complicated by anxiety and panic attacks. A…

addiction medicinegeneral practicesystemheroin
QLDhospital2022-07-07

S - Non-inquest findings

2y · Male·Crush chest injuries

A two-year-old boy died from crush chest injuries after a heavy homemade hallway table (approximately 70kg, made from a railway sleeper) toppled onto him while he was playing at home. He was found unresponsive by his par…

emergency medicinepaediatricssystem
VICaged care2022-07-06

Finding into death of Catherine Ann Collier

51y · Female·Aspiration in the setting of end stage down syndrome

Catherine Ann Collier, a 51-year-old woman with Down syndrome, end-stage hydrocephalus, and severe dysphagia, died from aspiration pneumonia following a choking episode while eating. The Disability Services Commissioner …

neurologyspeech pathologysystemcommunicationsodium valproate
NSW2022-07-06

Inquest into the death of Kevin BUGMY

57y · Male·Severe coronary artery disease. It is likely that Kevin's use of inhalants in cu…

Kevin Bugmy, a 57-year-old Aboriginal man, died of severe coronary artery disease while in custody at Cessnock Correctional Centre. The coroner found the care received for his chronic inhalant use disorder was grossly in…

cardiologygeneral practicediagnosticcommunicationacetone
NSWcommunity2022-07-05

Inquest into the deaths of Darren WALLACE and T B D

Male·Darren Wallace: single gunshot wound to right side of neck. TBD: two self-inflic…

Two deaths occurred on 9 December 2015 in a tragic incident connected to a dispute within the Rebels Outlaw Motorcycle Gang. TBD, a 31-year-old former ADF member with severe post-traumatic stress disorder (PTSD), alcohol…

psychiatryemergency medicinesystemdelaysertraline
TAScommunity2022-07-04

Coroner's Finding: Leighton, Garth Mcdonald

58y · Male·chest and abdominal injuries sustained in motor vehicle collision

A 58-year-old experienced motorcycle rider died from massive chest and abdominal injuries after losing control on a rural curve and colliding with an oncoming vehicle. He was initially conscious with three doctors presen…

emergency medicinesurgerysystemdelay
NSWcommunity2022-07-01

Inquest into the death of Mark MURPHY

49y · Male·Global cerebral hypoxia due to cardiac arrest and drowning, with bilateral bronc…

Mark Murphy, an experienced diver with 657 logged dives, died during an occupational diving course when his full face mask became accidentally dislodged underwater, resulting in sudden cold-water exposure. This triggered…

diving medicineemergency medicinesystemcommunication
QLD2022-06-30

Pini, Bailey Ezekiel

13y · Male·Effects of fire due to motor vehicle collision

A 13-year-old boy in youth residential care, grieving his mother's death one year prior, forcibly entered the facility office with a companion and stole a carer's car keys. They drove to their hometown, lost control of t…

systemdelay
QLDcommunity2022-06-29

Clarke, Hannah Ashlie; Baxter, Aaliyah Anne; Baxter, Laianah Grace; Baxter, Trey Rowan Charles; Baxter, Rowan Charles

Mixed·Hannah Clarke: multi-organ failure due to effects of fire; Aaliyah, Laianah and …

Hannah Clarke, aged 33, and her three children (ages 6, 4, and 3) were killed by her estranged husband Rowan Baxter on 19 February 2020 in Camp Hill, Queensland. Baxter forced his way into Hannah's car, doused the family…

emergency medicineparamedicinediagnosticcommunication
VICmental health2022-06-29

Finding into death of Melissa Gaultier

34y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian), in circums…

Melissa Gaultier, 34 years old, was discharged from Latrobe Regional Hospital's psychiatric ward (Flynn Unit) less than 24 hours after admission on 13 April 2017, despite comprehensive warnings from Monash Health that sh…

psychiatryobstetricscommunicationdiagnostic
QLDhome2022-06-27

Langham, Doreen Gail and Hely, Gary Matthew

49y · Female·Doreen Langham: combination of spleen injury and effects of fire; Gary Hely: eff…

Doreen Langham was killed by her intimate partner Gary Hely in an intimate partner homicide-suicide on 22 February 2021 in Queensland. The death was preceded by extensive domestic violence including physical assaults, co…

forensic medicinepsychiatrydiagnosticcommunicationcannabis
VIChome2022-06-27

Finding into death of Master J

3y · Male·Neck compression due to entanglement in the cord of a blind

A 3-year-old boy died from neck compression due to entanglement in a vertical blind cord while in his mother's care. He was left unsupervised in a lounge room with free-standing blind cords that were not affixed to the w…

system
VICcommunity2022-06-24

Finding into death of H YO

44y · Male·Heroin toxicity

A 44-year-old man with a 24-year history of opioid addiction died from heroin toxicity two days after release from prison on a Community Corrections Order. He had been on opioid replacement therapy (Suboxone) but discont…

addiction medicinecorrectional healthsystemdelayheroin
NSWaged care2022-06-24

Inquest into the death of Thomas FULCHER

70y · Male·hypovolaemic shock due to the consequences of fractured femur

Thomas Fulcher, a 70-year-old man with intellectual disability and osteoporosis in a group home, fell on 19 January 2018 and sustained a spiral femur fracture with internal bleeding. Care workers failed to seek medical a…

orthopaedic surgeryemergency medicinediagnosticcommunication
WAhospital2022-06-23

Inquest into the Death of Lee MILCHERDY

75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…

Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the plann…

gastroenterologygeneral surgerycommunicationdiagnostic
VIChome2022-06-22

Finding into death of Mr Y

46y · Male·Neck compression by ligature suspension

Mr Y, a 46-year-old man with a history of alcohol use and family violence perpetration, died by suicide via neck compression by ligature suspension in May 2020. He had expressed suicidal ideation to his wife on multiple …

general practicepsychiatrycommunicationsystem
WA2022-06-21

Inquest into the Death of Ashley Adrian LANE

56y · Male·acute exacerbation of chronic obstructive pulmonary disease (bronchial asthma) i…

Ashley Adrian Lane, a 56-year-old Aboriginal man from the Ngaanyatjarra Lands, died in custody at Kalgoorlie Regional Hospital from acute exacerbation of chronic obstructive pulmonary disease (asthma). He was a remand pr…

respiratory medicineemergency medicinediagnosticcommunicationsalbutamol
WA2022-06-17

Inquest into the 4 Deaths at Mount Augustus

heat stroke (environmental exposure) / hyperthermia; Mr Buske: atherosclerotic h…

Four deaths occurred on Mount Augustus summit trail in 2019-2020 during hot weather conditions. All deceased experienced heat stroke with dehydration as the primary mechanism of death. The coroner identified inadequate p…

emergency medicineforensic medicinesystemcommunication
SAhospital2022-06-17

Coroner's Finding: THREDGOLD, Holly Alexandra

42y · Female·hanging

Holly Thredgold, aged 42, died by hanging on 28 August 2016, less than 40 hours after inappropriate discharge from Royal Adelaide Hospital ED. She presented on 26 August 2016 severely intoxicated with suicidal ideation a…

emergency medicinepsychiatrycommunicationdiagnosticsertraline
QLDhome2022-06-17

CJ - Non-inquest findings

14y · Male·Hanging

A 14-year-old boy died by hanging after extensive exposure to domestic and family violence and child abuse, primarily from his father. Child Safety Services involvement began in infancy but failed to apply a trauma-infor…

paediatricspsychiatrydiagnosticcommunicationcannabis

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