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VIC2021-09-15

Finding into death of Cheryl Anne Taylor

59y · Female·mechanical asphyxia

Cheryl Anne Taylor, aged 59, died from mechanical asphyxia when a timber balcony collapsed at a Christmas party on 16 December 2017. The balcony had multiple structural deficiencies: the main support bearer was undersize…

emergency medicinesystemdelay
VIC2021-09-15

Finding into death of Sarah Michele Kajoba

37y · Female·Multiple injuries

Sarah Michele Kajoba, aged 37, died from multiple traumatic injuries sustained when a timber balcony collapsed at a Christmas party on 16 December 2017. The balcony had been undersized from construction in 1987, with ina…

emergency medicinetrauma surgerysystemprocedural
WAhospital2021-09-14

Inquest into the Death of Jeremy Michael SCOTT

63y · Male·metastatic rectal carcinoma

Jeremy Scott, a 63-year-old prisoner, died from metastatic rectal carcinoma on 3 July 2017. From 2015 onwards, he reported rectal and anal symptoms including pain, bleeding, and palpable masses, which were repeatedly att…

general surgerycolorectal surgerydiagnosticcommunication
QLDcommunity2021-09-10

Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings

49y · Female and male·Gunshot wound to head inflicted by spouse

Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…

general practicepsychiatrydiagnosticcommunicationcannabis
WAhome2021-09-09

Inquest into the Death of Amy Lee WENSLEY

24y · Female·Shotgun injury to the head

Amy Wensley died from a shotgun wound to the head on 26 June 2014. Whether self-inflicted or inflicted by another remains undetermined. Detectives prematurely concluded suicide on the night of death without thorough inve…

forensic medicinetoxicologydiagnosticcommunicationcitalopram
VIChome2021-09-08

Finding into death of DA

38y · Male·Mixed drug toxicity

DA was a 38-year-old man who died from mixed drug toxicity involving sedating medications and alcohol. He had longstanding severe anxiety and became dependent on codeine and benzodiazepines, initially obtained from multi…

general practicepsychiatrycommunicationsystemcodeine
WAprison2021-09-06

Inquest into the Death of Marshall Ruben EDGILL

38y · Male·combined effects of acute-on-chronic respiratory disease and cardiomegaly

Marshall Ruben Edgill, a 38-year-old Indigenous man, died in custody from acute-on-chronic respiratory disease and cardiomegaly. He had longstanding obstructive sleep apnoea (OSA), obesity, asthma, and hypertension. Crit…

respiratory medicinecardiologydiagnosticdelay
QLD2021-09-02

Batalha, Benjamin John

35y · Male·Not determined

Benjamin Batalha, aged 35, died in custody at Arthur Gorrie Correctional Centre. The exact cause of death could not be determined, though respiratory depression from mixed drug toxicity or fatal arrhythmia were likely. H…

psychiatrycorrectional healthsystemdiazepam
VIChospital2021-09-02

Finding into death of Robena May Lloyd

58y · Female·Enterococcus faecalis sepsis and acute renal failure

Robena Lloyd, a 58-year-old woman with intellectual disability and schizophrenia, died from enterococcus faecalis sepsis and acute renal failure on 7 August 2009. She presented to Angliss Hospital ED on 31 July with urin…

emergency medicinenephrologydiagnosticcommunicationtrimethoprim
VIChome2021-08-31

Finding into death of Brendon Crippen

27y · Male·Effects of fire

Brendon Crippen, 27, died from severe burns sustained in a deliberately set fire at his family's property. He had recently absconded from a Tasmanian psychiatric unit where he was subject to a compulsory treatment order …

psychiatrycommunicationsystem
TAShospital2021-08-26

Coroner's Finding: PY

0y · Unknown·sepsis leading to multiple organ failure syndrome

A 48-day-old neonate with congenital heart defect presented to the ED with fever and vomiting on 20 September 2019. Initial triage as Category 3 was inappropriate; the child required urgent assessment. The ED intern saw …

paediatricsemergency medicinediagnosticdelayparacetamol
VIChome2021-08-26

Finding into death of Mrs A

61y · Female·Ligature neck compression in the setting of blunt force head trauma

A 61-year-old woman of Bulgarian descent was fatally assaulted by her estranged husband in a domestic violence incident. She died from ligature neck compression following blunt force head trauma. The perpetrator had mult…

general practicepsychologycommunicationsystem
VICcommunity2021-08-25

Finding into death of Garry Mark Wise

47y · Male·Hanging

A 47-year-old man with chronic schizophrenia and alcohol dependence died by hanging at a rooming house. He had been non-compliant with antipsychotic medications for months, experiencing severe auditory hallucinations tha…

psychiatrygeneral practicecommunicationsystemlurasidone
QLDcommunity2021-08-20

Dower, Sarahjane - Non-inquest findings

26y · Female·Neck injury due to stabbing

A 26-year-old woman was stabbed twice in the neck and fatally injured by her former de facto partner. Critical clinical and systemic failures preceded her death: her psychologist failed to notify police or health authori…

psychologypsychiatrydiagnosticcommunicationvenlafaxine
QLD2021-08-20

Caramin, Olivier Max - Non-inquest findings

27y · Male·multiple organ failure due to or as a consequence of heat stroke

Olivier Caramin, a 27-year-old Belgian national on a working holiday visa, died from heat stroke while picking pumpkins on 31 October 2017 in Far North Queensland. He was just three days into farm work without proper acc…

occupational and environmental healthemergency medicinesystemdiagnostic
VIChome2021-08-20

Finding into death of Samantha Louise Leech

28y · Female·Complications of a seizure in the setting of prescription drug abuse (pregabalin…

Samantha Leech, 28, died from complications of a seizure in the setting of prescription drug abuse, particularly pregabalin. She obtained approximately 4000 pregabalin tablets over three months by visiting multiple GPs, …

general practicecardiologydiagnosticsystempregabalin
NSWcommunity2021-08-18

Inquest into the death of A F

24y · Male·multiple stab wounds to the chest that he inflicted upon himself

A 24-year-old man with diagnosed schizophrenia experienced a relapse and engaged in a dangerous spree involving vehicle theft, assault, and police pursuit. Despite psychiatric treatment with antipsychotics, he stopped me…

psychiatrygeneral practicesystemcommunicationlurasidone
VIChome2021-08-12

Finding into death of M J

37y · Male·Acute external and internal blood loss from single stab wound to upper left ches…

MWJ, aged 37, was fatally stabbed by his intimate partner EW on 24 December 2016 during an escalating domestic argument. The coroner identified significant systemic failures in Community Corrections management of both of…

general practicepsychiatrysystemcommunicationmethamphetamine
VICaged care2021-08-12

Finding into death of Valerie Lucy Jones

86y · Female·Plastic bag asphyxia

An 86-year-old woman with delirium, depression, and multiple cardiac comorbidities died by asphyxiation with a plastic bag while in a transitional care facility. She had expressed wishes to die, references to suicide, an…

general medicinegeriatric medicinecommunicationsystemmirtazapine
WAcommunity2021-08-11

Inquest into the Suspected Death of Desmond Francis CARR

32y · Male·unknown cause, likely natural causes possibly complicated by accident in remote …

Desmond Carr, aged 32, disappeared on 2 August 1979 from a remote worksite near Thangoo Station, Broome, WA, while operating a steam roller for the Main Roads Department. He was in poor health with a history of seizures,…

systemdelayphenytoin

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