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VIC2022-04-04

Finding into death of Naser Vukovic

42y · Male·Incised injury to the neck resulting in exsanguination and air embolism

Naser Vukovic, a 42-year-old prisoner with severe psychotic symptoms and dual P1/S3 risk ratings, died by self-inflicted neck laceration in Melbourne Assessment Prison on 8 June 2016. Despite two prior self-harm incident…

psychiatrycorrectional healthsystemdelayquetiapine
VICcommunity2022-04-04

Finding into death of Andrew Francis Powell

32y · Male·Drowning

Andrew Powell, a 32-year-old volunteer lifesaver, drowned on 21 April 2019 while performing a rescue operation in rough seas at Port Campbell, Victoria. A tourist became trapped in strong currents at Sherbrook Beach. The…

communicationsystem
VIC2022-04-04

Finding into death of Ross William Powell

71y · Male·Drowning

Ross Powell, a 71-year-old experienced volunteer lifesaver, died by drowning on 21 April 2019 while operating the Pelican rescue vessel during a maritime emergency at Port Campbell, Victoria. A tourist (Mr Bhaskar) had e…

emergency medicinesystemcommunication
VIChome2022-03-31

Finding into death of Maria James

38y · Female·haemorrhage from stab wounds

Maria James was murdered in her home bookshop in Thornbury on 17 June 1980, stabbed 68 times. The killer has never been identified. This coronial inquest examined the adequacy of the original police investigation and ide…

forensic medicinesystemdelay
VIChome2022-03-31

Finding into death of Tessa Michelle Ballam

31y · Female·neck compression in the circumstances of hanging

Tessa Ballam, a 31-year-old accountant with longstanding depression, anxiety, bulimia nervosa, and borderline personality disorder (BPD), died by hanging in August 2015. She had experienced workplace difficulties with he…

psychiatrypsychologycommunicationsystemalcohol
VICprison2022-03-30

Finding into death of Charles Bertram Squires

76y · Male·Intracranial haemorrhage

Charles Bertram Squires, a 76-year-old prisoner on anticoagulant therapy (apixaban and aspirin), fell and struck his head on 26 January 2017. Nursing staff at the correctional facility inadequately assessed his traumatic…

emergency medicineneurosurgerydiagnosticcommunicationapixaban
VICmental health2022-03-30

Finding into death of B J

24y · Male·Hypoxic brain injury secondary to hanging

BJ, a 24-year-old with paranoid schizophrenia, substance abuse disorder, and anti-social personality disorder, died by hanging in a psychiatric unit after a suicide attempt. He was admitted on 4 January 2016 with suicida…

psychiatryemergency medicinecommunicationsystemquetiapine
NSWhome2022-03-30

Inquest into the deaths of Stacey DOCHERTY and Seth DOCHERTY

38 and 3y · Female and male·Stacey: hanging; Seth: undetermined causes (likely suffocation, drowning, or str…

Stacey Docherty, a 38-year-old woman with complex post-traumatic stress disorder and borderline personality disorder resulting from childhood sexual abuse, killed her 3-year-old son Seth before taking her own life in Mar…

psychiatrygeneral practicemedicationcommunicationalprazolam
NSWmental health2022-03-29

Inquest into the disappearance and suspected death of Helen Stacey

19y · Female·The available evidence does not allow for a finding as to the cause of death

Helen Stacey, a 19-year-old university student, disappeared on 19 August 1958 after absconding from Broughton Hall mental health facility. She had been referred for urgent psychiatric admission following concerning discl…

psychiatrygeneral medicinesystem
WA2022-03-28

Inquest into the Suspected Death of Michael Richard GRUBB

33y · Male·Drowning (unascertained - possible injury sustained upon reaching dinghy)

Michael Grubb, age 33, died by drowning in Cockburn Sound, Western Australia on 16 August 2019 after jumping from a yacht without a lifejacket to retrieve an adrift dinghy during severe weather conditions with gale-force…

systemdelay
WAhospital2022-03-28

Inquest into the Death of Morgan John EDWARDS

31y · Male·Complications in association with intestinal volvulus

31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…

emergency medicinegastroenterologydiagnosticcommunication
VIC2022-03-28

Finding into death of Deva Rebecca Frijlink

42y · Female·Choking on a food bolus

Deva Frijlink, aged 42 years with intellectual disability and schizoaffective disorder, died from choking on a food bolus during a supervised mealtime excursion. She was under the care of a support worker at a shared acc…

speech pathologyemergency medicinecommunicationsystemdiazepam
VIChome2022-03-25

Finding into death of Ms WJ

59y · Female·Sepsis in a woman with epilepsy, cerebral palsy and haemochromatosis

A 59-year-old woman with cerebral palsy, epilepsy, and intellectual disability died of sepsis from a urinary tract infection (urosepsis) caused by E. coli and Proteus mirabilis. She had four hospital presentations in the…

emergency medicinegeneral medicinecommunicationsystemmetoclopramide
NSWhospital2022-03-25

Inquest into the death of Anthony Barrett

54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…

Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…

orthopaedic surgeryvascular surgerycommunicationdiagnosticclopidogrel
VIC2022-03-24

Finding into death of Ivica Andrijasevic

54y · Male·neck compression

Ivica Andrijasevic, a 54-year-old boilermaker, died from neck compression after being crushed by a malfunctioning Mobile Elevated Work Platform (MEWP) at a construction site. The MEWP's jib switch was defective and faile…

systemprocedural
VIC2022-03-21

Finding into death of Nilofer Nezami

38y · Female·Unascertained

Nilofer Nezami, a 38-year-old Victorian resident, died on 7 January 2019 following cosmetic surgery in Iran. She underwent multiple procedures including eye, breast, arm and abdominal surgery. Post-operatively, she devel…

plastic and reconstructive surgeryanaesthesiasystemproceduralmorphine
VICcommunity2022-03-16

Finding into death of John Anthony Kamps

62y · Male·Hypoxic ischaemic encephalopathy complicating acute upper airway obstruction by …

John Kamps, a 62-year-old man with intellectual disability, autism, epilepsy, and dysphagia, died from hypoxic ischaemic encephalopathy following airway obstruction by food bolus. He choked on toast at breakfast despite …

speech pathologyemergency medicinesystemcommunication
VIChospital2022-03-15

Finding into death of Ann Leah Jones

87y · Female·Pulmonary artery rupture complicating pulmonary artery catheter insertion in a w…

Mrs Jones, an 87-year-old woman with severe ischaemic heart disease, died from pulmonary artery rupture during elective off-pump coronary artery bypass surgery. A Swan-Ganz pulmonary artery catheter (PAC) was inserted pr…

cardiothoracic surgeryanaesthesiaproceduralsystemfentanyl
TAScommunity2022-03-14

Coroner's Finding: PL

7y · Male·head injuries from ejection onto rocky riverbank during boating accident

A 7-year-old boy died from catastrophic head injuries after being ejected from a ski biscuit during a recreational boating accident on the Prosser River in Tasmania. The vessel operator was towing the child at excessive …

emergency medicineintensive careproceduralcommunication
NSWhospital2022-03-11

Inquest into the death of Kelvin Forrest

53y · Male·multiple injuries sustained in a fall from the first floor

Kelvin Forrest, a 53-year-old man with Down syndrome and dementia, died from multiple injuries sustained in a fall from the first floor of Byron Central Hospital on 28 July 2018. He had been admitted as a medical patient…

general medicinegeriatric medicinediagnosticcommunication

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