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NThomeNew2026-09-04

Inquest into the death of Death of 80 year old (Ambulance delay)

80y · Male·Aspiration pneumonia on background of fall with head strike and long lie

An 80-year-old man with multiple comorbidities (COPD, diabetes, osteoporosis, recurrent falls) fell at home on 4 February 2026 with a head strike. His wife called emergency services at 8:12am but an ambulance did not arr…

emergency medicinegeneral medicinesystemdelay
NTaged careNew2026-09-04

Inquest into the death of Death of 75 year old (Ambulance delay)

75y · Female·Acute subdural haematoma secondary to blunt force head trauma

A 75-year-old female nursing home resident fell with head strike on 9 January 2026 at 16:45. Ambulance was called at 17:05 (Priority 2) and upgraded to Priority 1 at 17:47 when she became less responsive. The response wa…

paramedicineemergency medicinesystemdelay
NTaged careNew2026-09-04

Inquest into the death of Death of 89 year old (Ambulance delay)

89y · Female·Complications following a fall (long lie, rib fractures and iatrogenic pneumotho…

An 89-year-old frail woman with dementia, COPD, and osteoporosis fell at her aged care facility and waited over 5 hours for ambulance response due to St John NT capacity shortages. A forensic pathologist concluded this p…

paramedicinegeriatric medicinesystemdelay
NThomeNew2026-08-31

Inquest into the death of SUDI death of 42-day old female

<1y · Female·Sudden unexpected death in an infant (SUDI) in an unsafe sleeping environment

This is a SUDI death of a 42-day-old Aboriginal infant who died in an unsafe sleeping environment due to co-sleeping with her mother on a single mattress in an overcrowded unit. The mother, a 21-year-old with complex tra…

midwiferypaediatricscommunicationsystemcannabis
VIChomeNew2026-08-31

Finding into death of Mitchell Dean Johns

28y · Male·Hypoglycaemia due to administration of exogenous insulin

Mitchell Johns, 28, died from hypoglycaemia following an intentional insulin overdose during a suicide attempt. He had Type 1 diabetes, depression, and chronic suicidal ideation. On 27 May 2021, he presented to Bendigo H…

emergency medicinepsychiatrycommunicationsystemnovorapid insulin aspart
NSWcustodyNew2026-08-20

Inquest into the death of Hugo Peter Diaz Knox

25y · Male·Cardiorespiratory arrest due to acute cocaine toxicity

Hugo Diaz Knox, 25, died from cardiorespiratory arrest due to acute cocaine toxicity following his arrest for a positive roadside drug test. The coroner found he ingested a massive, fatal dose of cocaine (35mg/L blood co…

paramedicineemergency medicinecommunicationsystemcocaine
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
VICcommunity2026-08-17

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
VIChospitalNew2026-08-11

Finding into death of Belinda Ann Jones

40y · Female·Streptococcal and staphylococcal meningitis, endocarditis and septicaemia

Belinda Ann Jones, 40, died on 19 July 2023 from bacterial meningitis, endocarditis, and septicaemia secondary to osteomyelitis pubis. She presented to Maryborough District Health Service on 14 July with severe back pain…

emergency medicinegeneral practicediagnosticcommunicationmethamphetamine
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
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
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
SAhome2026-07-13

Coroner's Finding: Low, David John

64y · Male·ischaemic and hypertensive heart disease (operated) with cardiomegaly with contr…

A 64-year-old man with ischaemic heart disease, cardiomegaly, diabetes and obesity died at home from cardiac failure after calling his care worker for assistance. A paramedic arrived but refused to force entry, instead a…

cardiologyparamedicinesystemdelay
WAhome2026-06-29

Inquest into the Death of David William LAVARS

Male·phosphine toxicity in a man with atherosclerotic heart disease

Robert Lavars died on 6 September 2022 after deliberately ingesting aluminium phosphide tablets while under police arrest at his home in Shoalwater. He had serious health conditions including strokes, heart disease, and …

toxicologyparamedicineproceduralcommunicationaluminium phosphide
QLDcommunity2026-06-26

Inquest into the death of Wayne Thomas Kerle

68y · Male·Cardiac arrest - unascertained etiology with multiple contributing factors inclu…

Wayne Thomas Kerle, 68, was arrested at his home for cannabis possession. Queensland Ambulance Service paramedics assessed him when he reported respiratory distress but cleared him for police custody after a limited exam…

paramedicineemergency medicinediagnosticproceduraldiazepam
QLDhome2026-06-17

Inquest into death of Steven Richard Angus

52y · Male·Gunshot wound to the chest

Steven Richard Angus, a 52-year-old veteran with severe alcohol use disorder, major depressive disorder, and generalised anxiety disorder, died from a gunshot wound inflicted by Queensland Police during a welfare check o…

emergency medicinepsychiatrysystemcommunicationalcohol
SA2026-06-02

Coroner's Finding: Taylor, Nathan James

40y · Male·Unascertained

Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…

cardiologygeneral medicinediagnosticsystempaliperidone
VIChome2026-04-30

Finding into death of Nick Panagiotopoulos

47y · Male·Acute myocardial infarction due to thrombotic occlusion of the right coronary ar…

Nick Panagiotopoulos, a 47-year-old man, suffered a fatal acute myocardial infarction (heart attack) on 16 October 2021 at home in Preston, Victoria. His family made five calls to Triple Zero (000) requesting emergency a…

cardiologyemergency medicinesystemdelay
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