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VICaged care2026-05-06

Finding into death of Cornelia Groot

87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…

An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…

geriatric medicineemergency medicinediagnosticcommunicationoxycodone
VIChospital2026-04-16

Finding into death of Damien Mark Stone

53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures

Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…

emergency medicineneurologydiagnosticcommunicationoxycodone
NSWcommunity2026-03-25

Inquest into the death of Jesse Riley

31y · Male·Status epilepsy secondary to cerebral cavernoma

Jesse Riley, a 31-year-old with undiagnosed cerebral cavernoma, experienced status epilepticus triggered by an unknown cause (possibly nicotine from recent vaping). While in post-ictal delirium, he was perceived as aggre…

paramedicineemergency medicinecommunicationsystemdroperidol
WAhospital2026-02-23

Inquest into the Death of Child MML

11y · Male·bronchopneumonia and small bowel necrosis with perforation, in a boy with multic…

An 11-year-old Aboriginal boy died from bronchopneumonia and small bowel necrosis with perforation, following severe neurological impairment from an inflicted brain injury sustained at 8 months old. His parents delayed s…

neurologypaediatricscommunicationsystem
VIChome2026-02-17

Finding into death of Laurence Mark O'brien

22y · Male·Mixed drug toxicity (tapentadol, clonazepam, citalopram, amphetamine, olanzapine…

Laurence O'Brien, a 22-year-old with acquired brain injury from a childhood motor vehicle accident, died from mixed drug toxicity involving eight substances including prescribed opioids, benzodiazepines, and unprescribed…

general practicepsychiatrymedicationsystemtapentadol
NTcommunity2026-01-23

Inquest into the death of Kumanjayi Johnson

45y · Male·Environmental exposure and dehydration

A 45-year-old Aboriginal man with severe cognitive impairment (6.5-year-old equivalent English comprehension), traumatic brain injury, epilepsy and multiple medical conditions died from environmental exposure and dehydra…

geriatric medicinepsychiatrycommunicationsystem
VICaged care2026-01-16

Finding into death of F M

40y · Female·Sudden unexpected death in epilepsy (SUDEP) in a woman with schizophrenia

FM, a 40-year-old woman with epilepsy and schizoaffective disorder, died from sudden unexpected death in epilepsy (SUDEP) at her disability group home. She had been prescribed periciazine (Neulactil) five days before dea…

neurologypsychiatrysystempericiazine
WAcommunity2026-01-08

Inquest into the Suspected Death of John Howitson FRYLINCK

70y · Male·unascertained - likely exposure or natural causes such as a medical episode

John Frylinck, a 70-year-old man with Alzheimer's disease and poorly controlled type 2 diabetes, disappeared on 18 January 2024 while walking at Mundaring Sculpture Park. Despite an extensive search involving 120 volunte…

geriatric medicineneurologysystemdonepezil
VIChospital2026-01-08

Finding into death of Linette Ann Hawkins

80y · Female·Injuries sustained in a motor vehicle collision (driver)

An 80-year-old woman died from injuries sustained in a motor vehicle collision after likely experiencing a seizure or similar medical episode while driving. She had a history of traumatic brain injury from 1972 and a doc…

neurologytrauma surgerycommunicationsystemlevothyroxine
WAhome2025-12-22

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

14y · Male·epilepsy in a boy with Influenza B and COVID-19 infections

A 14-year-old Aboriginal boy with newly diagnosed epilepsy died unexpectedly on 24 August 2023 after an unwitnessed seizure while sleeping at his residential care home. He had been diagnosed with epilepsy in June 2023 fo…

paediatricsneurologycommunicationsystemsodium valproate
NSWhospital2025-12-19

Inquest into the death of JBO

27y · Female·Cardiac arrhythmia (first confirmed as ventricular fibrillation) of unascertaine…

A 27-year-old Aboriginal woman suffered sudden cardiac arrhythmia (ventricular fibrillation) immediately after recording video evidence of a suspected breach of her protective apprehended personal violence order (APVO). …

emergency medicinecardiologycommunicationsystemamiodarone
NSW2025-12-08

Inquest into the death of Benjamin Cullen

41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…

Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from P…

neurologyemergency medicinemedicationsystemlevetiracetam
SAcommunity2025-10-17

Coroner's Finding: Hall, Robert Lloyd

66y · Male·multiple injuries sustained in motor vehicle collision

A 66-year-old cyclist was struck and killed from behind by a driver with left absolute homonymous hemianopia (left-sided visual field loss) who was not scanning to compensate for his disability. The driver had suffered a…

neurosurgeryneurologysystemcommunication
VIChospital2025-10-10

Finding into death of Jeffrey George Nirens

70y · Male·intracranial haemorrhage secondary to haemorrhagic transformation of ischaemic s…

A 70-year-old man with chronic small vessel cerebral ischaemia died from intracranial haemorrhage following haemorrhagic transformation of an ischaemic stroke while in prison custody. He presented with acute stroke sympt…

neurologyemergency medicinemedicationsystemenoxaparin
VICcommunity2025-08-27

Finding into death of Harley James Smith

7y · Male·multiple injuries sustained in a motor vehicle collision (passenger)

A 7-year-old boy died in a head-on motor vehicle collision after his father deliberately drove their newly purchased car into an oncoming truck. The father had recently experienced severe stress following his partner's d…

paediatricspsychiatrycommunicationsystemmirtazapine
VIChospital2025-08-21

Finding into death of Andrew William Barr

54y · Male·Complications of pelvic and spinal fractures sustained in a fall in man with Dow…

Andrew William Barr, a 54-year-old man with Down syndrome and Alzheimer's dementia, died from complications of pelvic and spinal fractures sustained in a fall. Following his mother's death in January 2021 and his Februar…

orthopaedic surgerypalliative carecommunicationsystemanti-epileptic medication
VIChospital2025-07-30

Finding into death of MHT

86y · Male·Complications of blunt force trauma in a man with cardiac amyloidosis and athero…

An 86-year-old man with dementia, cardiac amyloidosis and atherosclerotic cardiovascular disease died from complications of blunt force trauma sustained in an assault by his adult son. The deceased had been diagnosed wit…

emergency medicineneurosurgerysystemcommunicationondansetron
VICcommunity2025-07-17

Finding into death of John Michael Jurdeczka

62y · Male·Hypoxic ischaemic encephalopathy complicating cardiac arrest in setting of acute…

John Michael Jurdeczka, a 62-year-old man with autism, intellectual disability, and dysphagia, died from hypoxic ischaemic encephalopathy following cardiac arrest caused by acute upper airway obstruction from a food bolu…

speech pathologygeneral practicecommunicationsystemmorphine
VIChospital2025-06-25

Finding into death of RFV

87y · Male·Consequences of an assault with severe facial fractures

RFV, an 87-year-old man, died from severe facial fractures and traumatic brain injury sustained during an assault by his daughter-in-law. He presented to hospital in critical condition with cardiac arrest, multiple facia…

emergency medicineintensive caresystem
TAScommunity2025-06-20

Coroner's Finding: Haig, Jeff

60y · Male·Undetermined - likely natural causes (centriacinar emphysema) or misadventure (f…

Jeff Malcolm Haig, a 60-year-old man with multiple sclerosis and documented paranoid and delusional beliefs about being monitored, was found deceased at Low Head, Tasmania on 26 August 2022, having last been seen alive o…

neurologygeneral practicesystemalcohol
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