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VIChospital2024-08-14

Finding into death of Gayle Dianne Ireland

63y · Female·Sepsis with multiorgan failure in the setting of limb cellulitis complicating a …

A 63-year-old woman with multiple comorbidities (obesity, chronic lung disease, obstructive sleep apnoea, prior cerebrovascular disease with hemiparesis) sustained a 4cm laceration to her right shin from a motorised whee…

emergency medicineintensive carediagnosticdelayceftriaxone
NSWcommunity2024-08-13

Inquest into the death of Brett Walker

37y · Male·multiple gunshot wounds

Brett Walker, 37, was shot by police on 9 July 2022 after a domestic violence incident 23 days post-release from prison. He had long-standing drug addiction and mental health issues including paranoid ideation, particula…

psychiatryaddiction medicinesystemcommunicationcrystal methamphetamine
QLDhospital2024-08-13

Non-inquest findings into the death of RJH

70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide card…

A 70-year-old woman with complex cardiac history including heart failure, paroxysmal atrial fibrillation, and coronary atherosclerosis presented with urinary tract infection and atrial fibrillation on Christmas Day 2021.…

cardiologyemergency medicinediagnosticmedicationflecainide
NSWhome2024-08-09

Inquest into the death of Linus Phillips

65y · Male·Cardiac arrhythmia, probably Torsades de Pointes, due to the combined effects of…

Linus Phillips, age 65, died at home in October 2014 from cardiac arrhythmia (Torsades de Pointes) precipitated by methadone prescribed with inadequate oversight. Mr Phillips had chronic pain from knee surgery, severe sl…

general practiceaddiction medicinediagnosticmedicationmethadone
TAShome2024-08-09

Coroner's Finding: Mansell-Moore, Codie

17y · Male·epileptic seizure complicating idiopathic epilepsy

17-year-old Codie Mansell-Moore died from epileptic seizures on 10 December 2018. An ambulance was called at 6:09am while he was seizing, but paramedics staged around the corner and did not enter his home for 48 minutes …

emergency medicineparamedicinecommunicationsystemlevetiracetam
NSWcustody2024-08-08

Inquest into the death of Phillip Boney

43y · Male·hanging

Phillip Mitchell Boney, a 43-year-old First Nations man, died by hanging in a correctional centre cell containing an obvious ligature point (exposed metal railings). He was under extended supervision in the community whe…

psychiatrygeneral practicecommunicationsystemmirtazapine
VIChome2024-08-08

Finding into death of Alan Edward Stewart

70y · Male·haemoperitoneum secondary to ruptured spleen following colonoscopy

Alan Edward Stewart, aged 70, died from haemoperitoneum due to splenic rupture following routine colonoscopy at Royal Melbourne Hospital on 15 August 2018. The splenic injury was caused by mechanical trauma from the colo…

gastroenterologyemergency medicinecommunicationsystemparacetamol
VIChospital2024-08-08

Finding into death of Alan Edward Stewart

70y · Male·haemoperitoneum and ruptured spleen following colonoscopy

Alan Stewart, aged 70, died from a ruptured spleen about 24 hours after an elective colonoscopy at Royal Melbourne Hospital. The splenic injury resulted from mechanical trauma during the procedure—an extremely rare compl…

gastroenterologyemergency medicinediagnosticcommunication
NSWhome2024-08-06

Inquest into the death of Dion Moore

29y · Male·Mixed drug toxicity, most significantly methamphetamine and buprenorphine, with …

Dion Moore, a 29-year-old Aboriginal man, died on 5–6 January 2019 from mixed drug toxicity (methamphetamine and buprenorphine), with heat and dehydration as significant contributing factors. After running out of fuel wi…

diagnosticdelaymethamphetamine
VIChospital2024-08-06

Finding into death of Noah Andrew Souvatzis

1y · Male·acute meningitis from Streptococcus pneumoniae, associated with diffuse brain sw…

Noah Souvatzis, a 19-month-old boy, died from Streptococcus pneumoniae meningitis on 31 December 2021 after presenting to Northeast Health Wangaratta ED on 29 December. Critical failures in his first ED presentation incl…

emergency medicinepaediatricsdiagnosticproceduralondansetron
TAShome2024-08-05

Coroner's Finding: de-identified TJ

82y · Male·Self-inflicted partial contact shotgun wound of the head

An 82-year-old man with recently diagnosed myeloma died by self-inflicted shotgun wound. He had undergone intensive chemotherapy causing significant deterioration in physical health, mental state, and independence. Six w…

oncologygeneral practicecommunicationsystem
WAhome2024-07-31

Inquest into the Death of Joseph Charles ABELA

34y · Male·Gunshot injuries to chest and left shoulder

Joseph Abela, a 34-year-old with chronic paranoid schizophrenia and polysubstance use, died from gunshot wounds inflicted by police during a mental health welfare check on 25 October 2021. Critical clinical failures prec…

psychiatrycorrectional healthdiagnosticsystemhaloperidol
VICcommunity2024-07-29

Finding into death of Andrew David Berry

41y · Male·sympathomimetic syndrome

Andrew Berry, a 41-year-old man with a long history of methamphetamine use and criminal offending, died of sympathomimetic syndrome following arrest by police on 14 January 2020. He was arrested after attempting to break…

emergency medicineforensic medicinesystemdelaymethamphetamine
VIChospital2024-07-29

Finding into death of Shane Anthony Pappas

54y · Male·quetiapine toxicity in a man with ischaemic heart disease

Shane Pappas, a 54-year-old man with ischaemic heart disease, died from quetiapine toxicity after deliberately overdosing on multiple medications on 29 June 2021. He had experienced a recent relationship breakdown and pr…

psychiatryemergency medicinediagnosticcommunicationquetiapine
TAShospital2024-07-25

Coroner's Finding: Briffa, Gennette Anne

73y · Female·sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopi…

A 73-year-old woman died from sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass surgery. She had complex medical history with multiple post-operative complicatio…

bariatric surgerygeneral surgerydiagnosticdelayapixaban
QLDhome2024-07-22

Non-inquest findings into the domestic violence related death of a First Nations woman

31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…

A 31-year-old First Nations woman was killed by her partner during intimate partner violence. She was pregnant at the time of death. Despite multiple contacts with police, court services, employment agencies, and domesti…

general practiceobstetricscommunicationsystemmethamphetamine
WAmental health2024-07-19

Inquest into the Death of Phillip Benjamin VELTMAN

49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…

Phillip Veltman, 49, died of unascertained cause (likely cardiac arrhythmia with terminal aspiration) while an involuntary psychiatric patient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on…

psychiatryemergency medicinecommunicationsystemketamine
WA2024-07-10

Inquest into the Death of Jason Anthony THOMPSON

54y · Male·metastatic lung cancer with terminal palliative care

Jason Anthony Thompson, a 54-year-old long-term prisoner at Casuarina Prison, died from metastatic lung cancer. He collapsed on 17 February 2023 with suspected opioid overdose but was not transferred to hospital for appr…

emergency medicineoncologydelaynaloxone
VIChome2024-07-05

Finding into death of BC J

32y · Female·Neck compression in the setting of self-suspension

A 32-year-old woman with a documented history of intimate partner violence died by self-suspension. She had reported ongoing physical, sexual and psychological abuse to police on 12 May 2020 and was assessed under mental…

psychiatryforensic medicinecommunicationsystemvenlafaxine
VIC2024-07-01

Finding into death of Joshua Steven Kerr

32y · Male·methylamphetamine toxicity

Joshua Steven Kerr, a 32-year-old Aboriginal man with intellectual disability and substance use disorder, died from methylamphetamine toxicity on 10 August 2022 at Port Phillip Prison. After lighting a fire in his cell a…

emergency medicinepsychiatrydiagnosticcommunicationmethamphetamine

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