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NThome2025-12-05

Inquest into the death of Kumanjayi Fly

2y · Male·Hypoxic-ischaemic encephalopathy due to out of hospital cardiac arrest following…

A 2-year-old toddler died after falling into a septic tank in his family's public housing home in a remote Northern Territory community. The septic tank access cover was corroded and insecure due to systemic failures in …

systemdelay
QLDhospital2025-12-04

Inquest into the death of Dylan James Bell

28y · Male·Hanging

Dylan Bell, 28, died by hanging following discharge from Redland Hospital ED where he presented with acute psychosis, suicidal and homicidal ideation, and made three self-harm attempts by strangulation. Despite a concern…

psychiatryemergency medicinediagnosticcommunicationLSD
VIChome2025-12-04

Finding into death of Raymond John Flaherty

57y · Male·Mixed drug toxicity (heroin, methadone, benzodiazepines including novel benzodia…

Raymond John Flaherty, a 57-year-old Wurundjeri man with longstanding opioid and benzodiazepine dependence, died from mixed drug toxicity involving heroin, methadone, prescribed diazepam, unprescribed benzodiazepines inc…

addiction medicinegeneral practicesystemcommunicationheroin
VICcommunity2025-12-04

Finding into death of Mr PNF

60y · Male·Neck compression secondary to hanging

A 60-year-old man with Type 2 diabetes and low mood died by hanging within 24 hours of being interviewed by police regarding child sexual abuse allegations. While police identified that suspects are at heightened suicide…

general practicepsychiatrycommunicationsystemfluoxetine
TAScommunity2025-12-03

Coroner's Finding: de-identified JI

54y · Male·Global hypoxic brain injury, cardiac arrest and blunt trauma to cervical spine

JI, a 54-year-old man with chronic schizophrenia, died from global hypoxic brain injury, cardiac arrest and cervical spine trauma following a fall onto a metal grate during an altercation with another resident at support…

psychiatrygeneral practicesystemdiazepam
TAShome2025-12-02

Coroner's Finding: de-identified DQ

54y · Female·mixed drug toxicity (methadone and diazepam)

A 54-year-old woman with long-standing opioid use disorder died from mixed methadone and diazepam toxicity. She had tripled her methadone dose by injecting additional takeaway doses alongside her prescribed pharmacy dose…

general practicepharmacologydiagnosticmedicationmethadone
QLD2025-12-01

Non-Inquest findings into the deaths of Ashley Pangana Morris and Humbereto Ferreira Leite

Male·Multiple injuries due to or as a consequence of concrete wall collapse

Two workers, Ashley Morris (34) and Humberto Leite (55), were fatally crushed by collapsing concrete wall panels on 6 October 2016 while installing foul water settling tanks at Eagle Farm Racecourse. The work system desi…

occupational and environmental healthproceduralsystem
WA2025-11-28

Inquest into the Death of Cleveland Keith DODD

16y · Male·complications of ligature compression of the neck (hanging)

A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…

psychiatrypsychologyproceduralcommunication
TAShospital2025-11-28

Coroner's Finding: Clark, Dennis

83y · Male·Sepsis due to staphylococcus aureus bacteraemia following infection of a left an…

An 83-year-old man with heart and kidney failure died from sepsis caused by MSSA bacteraemia following infection at a peripheral intravenous catheter (PIVC) insertion site. Ambulance paramedics inserted the PIVC 56 hours…

emergency medicinesurgeryproceduralsystem
WAhospital2025-11-27

Inquest into the Death of Stephen Joseph SCHIPP

58y · Male·complications of oesophageal cancer, with terminal palliative care

Stephen Joseph Schipp, a 58-year-old sentenced prisoner, died from complications of oesophageal cancer with terminal palliative care at Bunbury Regional Hospital. He had been diagnosed with oesophageal carcinoma in Janua…

oncologypalliative caresystemdelaychemotherapy
VIChome2025-11-24

Finding into death of Suk Ching Annie Ng

64y · Female·Blunt Force Trauma to the Head in the Setting of Prolonged Lie; Metastatic Breas…

Annie Ng, aged 64, died from blunt force head trauma sustained in her home on 27 February 2024, with death occurring 9 March 2024 at Royal Melbourne Hospital. Her husband Chai, experiencing severe financial and psycholog…

oncologygeneral practicesystem
QLDrural property, community2025-11-21

Inquest into the deaths of Matthew Joseph Arnold; Rachel Clare McCrow; Alan Thomas Brendan Dare; Gareth Daniel Train; Nathaniel…

Constable Arnold: single gunshot wound to the chest. Constable McCrow: gunshot w…

On 12 December 2022, two Queensland Police Constables (Matthew Arnold, Rachel McCrow) and a civilian (Alan Dare) were fatally shot at 251 Wains Road, Wieambilla by Gareth and Nathaniel Train while responding to a missing…

emergency medicinepsychiatrycommunicationsystem
VICcommunity2025-11-18

Finding into death of Darren John Atkinson

50y · Male·Mixed alcohol and drug toxicity (clozapine, paracetamol, caffeine); cardiac hype…

A 50-year-old man with treatment-resistant schizoaffective disorder died from mixed alcohol and drug toxicity (clozapine, paracetamol, caffeine) combined with cardiac hypertrophy. He ceased his antipsychotic medication o…

psychiatryemergency medicinecommunicationsystemclozapine
VIChome2025-11-18

Finding into death of JZA

65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …

A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…

geriatric medicineinfectious diseasessystemcommunicationpholcodine
NSWcommunity2025-11-13

Inquest into the death of Bradley Vincent Balzan

20y · Male·gunshot wounds to the chest and abdomen

Bradley Balzan, 20, died on 23 December 2020 after being shot twice by NSW Police officer SC Vingerhoed during a police operation. The fatal encounter began when Nepean PACT officers stopped Bradley on a street without e…

forensic medicineoccupational and environmental healthproceduralcommunication
NSWcommunity2025-11-13

Inquest into the disappearance and suspected death of Gerald Whitefoot

44y · Male·undetermined

Gerald George Francis Whitefoot disappeared on 9 December 1977 from Miller, NSW, and is now presumed deceased. He was 44 years old at disappearance. The coroner found him deceased on the balance of probabilities, but cou…

communicationsystemdiazepam
QLDhome2025-11-12

Inquest into the deaths of Lizzie Reuben and Isei Navutovuto

Unknown·Ms Reuben: burns to 97% of body surface area. Mr Navutovuto: multiorgan failure …

Two individuals in a domestic relationship with a documented history of violence died from severe burns in a house fire on 9 August 2022. Police had attended the home hours earlier in response to a welfare concern about …

diagnosticsystemalcohol
VIC2025-11-12

Finding into death of Wendy Ann McCabe

40y · Female·hypoxic ischaemic encephalopathy due to ligature compression of the neck

Wendy McCabe, a 40-year-old woman with a history of depression, anxiety, substance use and previous self-harm, died of asphyxiation from ligature compression after fashioning a noose from a standard blanket in her police…

correctional healthemergency medicineproceduralcommunicationmethadone
VIC2025-11-10

Finding into death of Andrew Phillip John Kursinskis

57y · Male·Complications following food aspiration in a man with multiple co-morbidities

Andrew Kursinskis, a 57-year-old man with intellectual disability, dysphagia, autism, epilepsy and pica, died from complications following aspiration of chicken schnitzel while living in supported disability accommodatio…

speech pathologyemergency medicinesystemcommunicationlevetiracetam
VIChospital2025-11-10

Finding into death of Jason Hosier

39y · Male·mixed drug toxicity (methadone, benzodiazepines, olanzapine, zopiclone)

Jason Hosier, a 39-year-old man with complex mental health and substance use history, died from mixed drug toxicity following discharge from Sunshine Hospital. He was subject to an inpatient temporary treatment order and…

emergency medicinepsychiatrycommunicationsystemmethadone
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