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VIChomeNew2026-08-26

Finding into death of Judith Margaret Kerr

78y · Female·Multiple organ failure secondary to sepsis and renal failure due to bronchopneum…

A 78-year-old woman with cognitive impairment, depression, and complex care needs fell at home on 11 February 2022. Her sons delayed seeking medical help for 4 days, during which she developed aspiration pneumonia and wa…

emergency medicineintensive carecommunicationsystemmirtazapine
VIChospitalNew2026-08-21

Finding into death of Susanne Keating

64y · Female·Presumed massive pulmonary embolus

Mrs Keating, aged 64, presented to University Hospital Geelong ED with a two-day history of shortness of breath and cough, with known history of pulmonary embolism. Attending physicians appropriately considered PE as dif…

emergency medicinegeneral practicedelaysystem
VIChomeNew2026-08-20

Finding into death of Gayle Patricia Carley

77y · Female·Ischaemic heart disease

Gayle Patricia Carley, 77, collapsed unwitnessed at home with acute ischaemic heart disease on 19 October 2023. Ambulance paramedics arrived and initiated emergency treatment, but a MICA paramedic inadvertently administe…

emergency medicineparamedicinemedicationsystemmetaraminol
VICcommunityNew2026-08-17

Finding into death of Guy Christian Mason

48y · Male·Pulmonary thromboembolism

Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…

emergency medicinegeneral surgerydiagnosticsystemenoxaparin
NTcommunityNew2026-08-14

Inquest into the death of Road death 57 of 2024

47y · Male·Multiple blunt force injuries to the neck, chest and lower limbs sustained in a …

A 47-year-old male passenger died from multiple blunt force injuries (bilateral pneumothoraces, pulmonary contusions, ruptured spleen, pelvic fractures, cervical spine fracture with spinal cord haemorrhage) from a high-s…

emergency medicineforensic medicinesystemmethamphetamine
SAhome2026-08-12

Coroner's Finding: Sylvia, Kate Marie

32y · Female·cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage

Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. mis…

paramedicinegeneral medicinediagnosticcommunicationoral contraceptive pill
TASaged careNew2026-08-10

Coroner's Finding: Cox, Beverley Jane

88y · Female·Cardiac failure secondary to pacemaker failure and pacemaker battery exhaustion

This case involves an 88-year-old woman with a pacemaker who became lost to follow-up after her last clinic visit in May 2019, when no follow-up appointment was arranged. Without systematic tracking between the specialis…

cardiologygeneral practicesystemcommunication
NSW2026-08-07

Inquest into the death of Amanawel Ayai

23y · Male·complications of bowel obstruction by adhesions

A 23-year-old man in lawful custody at Parklea Correctional Centre presented on 7 January 2022 with severe chest pain, abdominal pain, vomiting, and dehydration, with a significant history of previous abdominal surgery a…

correctional healthgeneral practicediagnosticcommunicationmetoclopramide
ACThome2026-08-03

Inquest into the death of Felipe Esteban Alvarez (No 2)

Male·toxicity caused by a combination of methylamphetamine and morphine

Felipe Esteban Alvarez died on 30 March 2021 from toxicity caused by methylamphetamine and morphine (heroin) ingestion at his unit in Taylor, ACT. He collapsed after self-injecting heroin in the presence of others, inclu…

addiction medicineemergency medicinedelayproceduralheroin
VIChospitalNew2026-07-31

Finding into death of K M

Male·unascertained

KM, an adult with mental health conditions (anxiety, depression), opioid dependence, and hepatitis C, presented to Alfred Hospital ED on 20 December 2024 with bilateral lower leg cellulitis. After initial IV antibiotics,…

emergency medicinesystemdelay
VICaged care2026-07-29

Finding into death of Rosemary Elsie Harriet Jacoby

94y · Female·Drug toxicity (baclofen, gabapentin, oxycodone, pregabalin, zolpidem)

A 94-year-old residential aged-care resident died from drug toxicity after receiving another resident's medications. An agency nurse, unfamiliar with the patient and interrupted during medication preparation, failed to p…

general practiceemergency medicinemedicationcommunicationbaclofen
VICaged care2026-07-29

Finding into death of Lynette Patricia McHarry

69y · Female·Exacerbation of chronic obstructive pulmonary disease and ischaemic heart diseas…

Lynette McHarry, aged 69, died on 15 August 2024 at Casey Hospital following complications from a preventable medication error at Mooraleigh Hostel residential aged care facility. On 4 August, she was mistakenly administ…

geriatric medicinegeneral practicemedicationsystemclozapine
WAhome2026-07-28

Inquest into the Death of Travis John WALDER

32y · Male·multiple injuries

Travis Walder, 32, died by suicide on 24 August 2023 after being struck by a train. He had schizophrenia and opioid use disorder with prior suicide attempts. On 23 August, he became acutely agitated and psychotic at his …

psychiatryemergency medicinecommunicationsystemmethamphetamine
VIChospital2026-07-27

Finding into death of Alan Gordon Wolstenholme

72y · Male·Complications of suspected upper gastrointestinal tract haemorrhage, hospital ac…

A 72-year-old man with metastatic squamous cell lung cancer and multiple serious comorbidities was admitted to Ballarat Hospital in July 2024 with lethargy, fatigue, and rapid atrial fibrillation. Due to medication chart…

cardiologyemergency medicinemedicationsystembuprenorphine
VICcommunity2026-07-27

Finding into death of DH I

37y · Male·Multiple injuries sustained in a train incident

A 37-year-old Aboriginal man with chronic opioid use disorder and co-occurring mental health issues presented to Royal Melbourne Hospital's Mental Health, Alcohol and Other Drugs Hub after being found slumped in Melbourn…

emergency medicineaddiction medicinesystemheroin
VICcommunityNew2026-07-23

Finding into death of Andre Alistair Hei

44y · Male·Neck compression; Hanging

Andre Alistair Hei, a 44-year-old Māori man, died by suicide via hanging on 11 March 2025 at Fitzroy Town Hall. He had a complex psychiatric history including depression, complex PTSD, methamphetamine use disorder, and c…

psychiatryaddiction medicinesystemmethamphetamine
VIChospital2026-07-23

Finding into death of Vicki Karon Grigg

67y · Female·Pulmonary thrombo-embolism secondary to deep venous thrombosis, with contributin…

Vicki Grigg, 67, died from pulmonary embolism three days after discharge from Goulburn Valley Health. She had been admitted with influenza A exacerbating asthma and COPD, and received standard-dose anticoagulation prophy…

respiratory medicineemergency medicinemedicationcommunicationenoxaparin
QLDhome2026-07-20

Non-inquest findings into the death of Baby M

Female·Meconium aspiration syndrome

Baby M was born at home via unattended free birth after her mother had previously undergone caesarean section. The mother experienced rupture of membranes one day before labour and was at 42 weeks gestation, both risk fa…

obstetricsmidwiferysystem
TAScommunity2026-07-15

Coroner's Finding: Hubbard, Brady James

21y · Male·Cerebral temporal lobe uncal and cerebellar tonsillar herniation

Brady Hubbard, 21, died from traumatic brain injury with cerebral herniation after falling from an unsecured utility vehicle driven by Andrew Hilfenhaus at West Ulverstone Football Club in June 2023. While riding on the …

emergency medicineintensive carecommunicationdelayalcohol
SAhospital2026-07-14

Coroner's Finding: Rosenzweig, Colin Anthony

61y · Male·bronchopneumonia complicating cerebrovascular accident due to cardioembolism on …

A 61-year-old man with a mechanical aortic valve underwent colonoscopy requiring temporary warfarin cessation. Following the procedure, he was discharged with a plan to recommence warfarin but without clear postoperative…

general surgerycardiologymedicationcommunicationwarfarin

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