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VIC2022-03-10

Finding into death of Joanne Callahan

43y · Female·choking on a food bolus

Joanne Callahan, a 43-year-old woman with intellectual disability and autism, died from choking on a food bolus while attending a disability day program. Critical failures in communication between her residential care pr…

speech pathologyparamedicinecommunicationsystem
VIChome2022-03-10

Finding into death of PFS

50y · Female·Hanging

A 50-year-old woman died by hanging in December 2017 after a relationship characterised by family violence and her own depression. She had been in an intimate partner violence situation for years, had presented to ED wit…

psychiatrypsychologycommunicationsystemsertraline
VICaged care2022-03-09

Finding into death of Erica Hubai

51y · Female·Aspiration pneumonia

A 51-year-old woman with Sturge-Webber syndrome and poor swallowing ability presented to hospital with a cough and was admitted on 15 December 2017, following a choking incident at her group home. She died on 23 December…

general practicerespiratory medicinecommunicationsystem
QLDcommunity2022-03-08

Powell, Christopher Ian

54y · Male·Multiple injuries due to crane rollover (bucket passenger); fall from height exc…

A professional photographer aged 54 died when an elevated work platform (EWP) with a 70-metre boom collapsed at 50 metres height after a rear outrigger sank into unstable ground. The casualty suffered multiple traumatic …

occupational and environmental healthforensic medicinediagnosticsystem
VIChome2022-03-08

Finding into death of David Charles Shaw

57y · Male·Ischaemic and valvular heart disease

David Charles Shaw, 57, died of ischaemic and valvular heart disease with severe coronary artery atherosclerosis. He was enrolled in MePACS, a medical alarm service requiring daily button activation between 6-11am. When …

general practicecardiologysystemdelay
VIC2022-03-08

Finding into death of Dylan James Charlton-Smith

25y · Male·Hypoxic ischaemic brain injury due to hanging

Dylan Charlton-Smith, aged 25, died by hanging while in custody at Fulham Correctional Facility. A stressful visit from his partner preceded his death by approximately 50 minutes. A correctional officer identified distre…

psychiatryemergency medicinediagnosticcommunication
WAhospital2022-03-03

Inquest into Death of Van Tho NGUYEN

59y · Male·metastatic lung cancer, with palliation

Van Tho Nguyen, a 59-year-old remand prisoner with metastatic lung cancer, died of natural causes in a private hospital palliative care setting. He had been a lifelong smoker who developed advanced adenocarcinoma with bo…

oncologypalliative caresystemcommunicationchemotherapy agents
TAScommunity2022-03-01

Coroner's Finding: Gray, Alan Maurice

77y · Male·traumatic closed head injury due to a fall from standing

Alan Maurice Gray, 77, suffered a fall at a service station on 16 September 2020, hitting his head. He called for an ambulance at 7:54pm but paramedics did not arrive until 12:09am (4 hours 15 minutes delay). CT imaging …

emergency medicineneurosurgerydiagnosticsystem
VIChospital2022-02-28

Finding into death of Stephen David Johnston

64y · Male·Aspiration pneumonia with cerebral palsy as a contributing factor

A 64-year-old man with cerebral palsy, intellectual disability, dysphagia, and recurrent respiratory infections died of aspiration pneumonia. He was receiving disability support services through Melba Support Services. I…

general practicepalliative caresystem
VIChospital2022-02-28

Finding into death of H YR

77y · Female·Haemoperitoneum following cholecystectomy

A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication bu…

general surgeryintensive carediagnosticdelaywarfarin
WAmental health2022-02-25

Inquest into the Death of Jordan James WILLIAMS

20y · Male·head and neck injuries sustained when struck by train

Jordan James Williams, 20, died after being struck by a train following two absconsions from Kalgoorlie Health Campus mental health unit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Crit…

psychiatryemergency medicinesupervisioncommunicationolanzapine
VIChospital2022-02-25

Finding into death of Joseph Cardona

49y · Male·haemopericardium secondary to ruptured aortic dissection

Joseph Cardona, 49, died from ruptured aortic dissection with haemopericardium. He presented to the ED twice within 24 hours with severe central chest pain radiating to jaw, neck, and back, associated with hypertension. …

emergency medicinecardiologydiagnosticcommunicationoxycodone
NSWhospital2022-02-25

Inquest into the death of Carley METCALFE

41y · Female·unable to determine

Carley Metcalfe, aged 41, was found deceased in the Brunswick River in November 2017, three weeks after disappearing. She had presented to Lismore Base Hospital on 1-2 November 2017 with acute psychosis related to schizo…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
ACTcommunity2022-02-24

Inquest into death of DEAN CHRISTOPHER BRICE

28y · Male·Multiple drug toxicity (gamma hydroxybutyrate and methamphetamine) with cardiore…

Dean Christopher Brice, a 28-year-old man with longstanding mental health and substance abuse problems, died from multiple drug toxicity (GHB and methamphetamine) with aspiration pneumonia and hypoxic ischaemic encephalo…

psychiatryaddiction medicinesystemgamma hydroxybutyrate
TAS2022-02-24

Coroner's Finding: Scott, Paul Stephen

61y · Male·asphyxial death due to hanging

Paul Stephen Scott, aged 61, died by hanging while on leave from psychiatric inpatient care. He had been admitted to Spencer Clinic on 11 January 2018 with suicidal ideation and complex psychiatric presentation. Despite …

psychiatrygeneral practicesystemcommunicationvenlafaxine
VICcommunity2022-02-24

Finding into death of Peter Trimbos

52y · Male·Head injuries

Peter Trimbos, a 52-year-old lawyer, died by suicide following overwhelming psychological distress from multiple stressors: the deaths of his parents and father-in-law from COVID-19, and involvement in a highly publicise…

general practicepsychiatrysystemdelay
TAShome2022-02-23

Coroner's Finding: BR - deidentified

0y · Female·Undetermined - coroner unable to determine exact cause; unsafe sleeping environm…

A 5-month-old infant died suddenly in a co-sleeping environment with adults and a toddler in a queen-sized bed with adult bedding. Autopsy revealed no definitive cause but identified significant risk factors: unsafe slee…

paediatricsneonatologysystem
VIChospital2022-02-22

Finding into death of Matthew Lee Dongelmans

30y · Male·Complications of methylamphetamine toxicity

Matthew Dongelmans, aged 30, died from complications of methylamphetamine toxicity after being arrested for breaching a family violence intervention order. He consumed methylamphetamine prior to arrest, likely in panic w…

emergency medicineintensive caredelaysystemmethamphetamine
TAShome2022-02-18

Coroner's Finding: FL de-identified

17y · Unknown·hypoxic brain damage from out of hospital cardiac arrest

FL was a 17-year-old with complex medical needs including short bowel syndrome and dependence on total parenteral nutrition (TPN) via central vascular access device. In June 2020, he became severely unwell with deteriora…

paediatric surgerygastroenterologydiagnosticdelay
VICcommunity2022-02-18

Finding into death of Roger David Batchelor

57y · Male·Hypoxic ischaemic encephalopathy secondary to prolonged downtime due to upper ai…

A 57-year-old man with intellectual disability and a documented history of choking died from hypoxic ischaemic encephalopathy following airway obstruction by food at a day activities program. Despite having a choking man…

general practicespeech pathologycommunicationsystempantoprazole

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