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WA2021-12-21

Inquest into the Death of James Alexander TILBURY

77y · Male·early pneumonia in an elderly man receiving terminal palliative medical care for…

James Tilbury, a 77-year-old long-term prisoner, died from early pneumonia while receiving palliative care for an atypical brain meningioma. He had complex chronic conditions including COPD, prostate cancer, ischaemic he…

palliative careneurosurgerycommunicationsystemdexamethasone
WA2021-12-21

Inquest into the Death of Child JP (Name Subject to Suppression Order)

16y · Male·multiple injuries sustained in motor vehicle crash

A 16-year-old unlicensed driver died in a high-speed crash while being pursued by unmarked police over 14 km. The driver attempted a dangerous overtaking manoeuvre on a gravel verge while evading police. Two detectives i…

proceduralcommunicationcannabis
ACTaged care2021-12-21

Inquest into the death of BRANDON GEOFFREY SAGER

43y · Male·asphyxia due to hanging - suicide

Brandon Sager, 43, died by suicide at the Brian Hennessy Rehabilitation Centre while subject to a psychiatric treatment order. He had a long history of schizophrenia and prior suicide attempts but had shown no signs of s…

psychiatrysystem
TAShome2021-12-21

Coroner's Finding: O'Donnell, Margaret Joy

51y · Female·Cannot be determined; likely mixed drug (including alcohol) toxicity or undeterm…

Margaret Joy O'Donnell, aged 51, died between 9-15 June 2018. The cause of death could not be determined due to decomposition, but toxicology revealed mixed drug toxicity including fatal levels of methadone and hydromorp…

general practicepsychiatrymedicationsystemoxycodone
VIChome2021-12-21

Finding into death of Geoffrey Alan Locks

50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…

A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleedin…

ENT surgeryoncologysystemcommunicationmethadone
NSWcommunity2021-12-21

Inquest into the deaths of Lars FALKHOLT, Vivian FALKHOLT, Jessica FALKHOLT and Annabelle FALKHOLT, and Craig WHITALL

Male·Combined effects of multiple blunt force injuries and the effects of fire (Craig…

Craig Whitall, a 49-year-old on methadone maintenance therapy, drove erratically on the Princes Highway after leaving hospital on Boxing Day 2017, colliding head-on with the Falkholt family vehicle, killing five people. …

general practiceemergency medicinemedicationcommunicationmethadone
NSWhome2021-12-20

Inquest into the death of Harland SUTTON

5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained

A 5-month-old premature infant with low birth weight died suddenly and unexpectedly at home. Toxicological testing revealed the presence of frusemide (a diuretic medication) in his blood and other samples, which should n…

paediatricsemergency medicinesystemmedicationfurosemide
TAShome2021-12-17

Coroner's Finding: Tilley, Jennifer May

58y · Female·undetermined; possible mixed drug intoxication and/or adrenal insufficiency

Jennifer May Tilley, aged 58, died on 8 January 2018 with an undetermined cause, though mixed drug intoxication and adrenal insufficiency were potential contributors. She had complex medical conditions requiring chronic …

general practicerheumatologysystemcommunicationpethidine
VIC2021-12-17

Finding into death of KW

4y · Unknown·Drowning

A 4-year-old boy drowned in a resort pool during a family birthday party on 13 December 2020. Despite wearing a buoyancy vest initially, he removed it to use water slides more freely. While approximately 8 adults were pr…

emergency medicineanaesthesiasystemdelay
VIChome2021-12-17

Finding into death of Barry Gray

72y · Male·Multiple stab and incised wounds to the chest and neck

Barry Gray, aged 72, was killed by his 22-year-old neighbor John Woodruff on 16-17 May 2013. Woodruff had been diagnosed with first episode psychosis in prison and released on a Community Corrections Order (CCO) on 30 Ap…

psychiatrycorrectional healthcommunicationsystemolanzapine
VIChome2021-12-17

Finding into death of B H

49y · Male·hanging

A 49-year-old man with a history of PTSD, depression and anxiety died by suicide following police service of a warrant to vary a family violence intervention order. He learned for the first time on 2 December 2017 that h…

psychiatrypsychologycommunicationsystemantidepressant medication
VIC2021-12-17

Finding into death of K W

4y · Male·Drowning

A 4-year-old boy drowned in a resort pool during a birthday party. He had been wearing a buoyancy vest initially but removed it to use water slides more freely. While approximately 20 people attended (8 adults), supervis…

systemdelay
VIChome2021-12-17

Finding into death of KF Z

25y · Male·Combined flualprazolam and alcohol toxicity

A 25-year-old man died from combined flualprazolam and alcohol toxicity after ingesting illicit drugs. He consumed alcohol heavily with housemates on 8 May 2021, then took a counterfeit 'Xanax' tablet containing flualpra…

forensic medicinetoxicologysystemflualprazolam
NSWcommunity2021-12-17

Inquiry into the fire at Reedy Swamp Tarraganda Bega/Tathra

Death from fire exposure during bushfire - the finding does not concern individu…

On 18 March 2018, a major bushfire commenced in an electrical easement near Reedy Swamp and rapidly spread to the coastal town of Tathra on the NSW South Coast, destroying approximately 1,400 hectares of bushland and dam…

systemcommunication
QLDPodcast2021-12-16

Brown, Casey Lenard

22y · Male·Head injury from bus rollover accident while unrestrained passenger

A 70-year-old bus driver experienced momentary inattention while driving a route service bus, causing it to drift off the road, strike a culvert and roll onto its side. Casey Lenard Brown, a 22-year-old passenger, died f…

system
WA2021-12-15

Inquest into the Death of Ohm SATHITPITTAYAYUDH

38y · Male·cardiac arrhythmia with acute circulatory failure in a man with acute drug effec…

Ohm Sathitpittayayudh, aged 38, died in custody at Karnet Prison Farm from cardiac arrhythmia with acute circulatory failure after ingesting 5F-ADB (Kronic), a synthetic cannabinoid. He had exemplary prison behaviour, go…

toxicologyforensic medicinesystem5f-adb
WAhome2021-12-15

Inquest into the Death of Child J (Name Subject to Suppression Order)

15y · Male·ligature compression of the neck (hanging)

Aboriginal child in out-of-home care died by hanging following relationship breakdown. He experienced foetal alcohol spectrum disorder, early trauma and neglect, and 34 different living arrangements. Despite specialist m…

psychiatrypaediatricssystemdelay
NSW2021-12-15

MACKANDER Bailey 2019-351386 - REDACTED Findings gicen by Mag Truscott DSC on 15-12-2021 can be published

20y · Male·Multiple injuries from fall from height

Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, disclosed suicidal ideation to a prison psychologist. This led to his placement on a Risk Intervention Team management plan requiring…

psychiatrypsychologydiagnosticsystemmethamphetamine
SA2021-12-15

Coroner's Finding: Lanzafame, Anthony

54y · Male·compression of the neck due to hanging

Anthony Lanzafame, a 54-year-old remand prisoner, died by hanging in his single cell at Adelaide Remand Centre on 24 May 2016. He had been on remand for 17 months facing murder charges and was undergoing trial when he di…

psychiatrycorrectional healthsystemolanzapine
NSWhospital2021-12-15

Inquest into the death of Bailey Mackander

20y · Male·Multiple injuries from fall from height

Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, died from multiple injuries after impulsively jumping an 8-metre wall at a hospital ambulance bay on 5 November 2019. He was in custo…

psychiatrypsychologydiagnosticcommunicationmethamphetamine

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