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VIChospitalNew2026-07-01

Finding into death of HJW

69y · Female·Urosepsis secondary to anuric acute renal failure and corona radiata infarct; co…

A 69-year-old diabetic woman presented to Maroondah Hospital Emergency Department on 9 June 2024 with severe right-sided abdominal pain and vomiting. CT imaging at 10:00am confirmed emphysematous pyelitis (gas-forming ki…

emergency medicinegeneral medicinediagnosticdelayfentanyl
QLDcommunityNew2026-06-26

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
NSWNew2026-06-11

Inquest into the death of Dictor Dongrin

29y · Male·Cardiac arrhythmia in the context of alcohol withdrawal and chronic alcohol misu…

A 29-year-old man died from cardiac arrhythmia in the context of severe alcohol withdrawal at a correctional facility. Initial assessment correctly identified moderate-to-severe withdrawal (AWS score 8) with seizure hist…

addiction medicinecorrectional healthdiagnosticmedicationalcohol
VIChome2026-05-29

Finding into death of Baby R

0y · Male·Perinatal hypoxia

Baby R, born at 39 weeks 6 days via planned homebirth with private midwives, died from perinatal hypoxia on day 6 of life. The mother had significant obstetric risk factors: previous emergency caesarean section, macrosom…

obstetricsmidwiferydiagnosticcommunication
VIChospital2026-05-22

Finding into death of Stratos Ioannidis

45y · Male·focal coronary artery disease and cardiomegaly

Stratos Ioannidis, age 45, died at Maroondah Hospital on 28 March 2025 from focal coronary artery disease and cardiomegaly during an involuntary psychiatric admission. He presented with acute psychosis from bipolar disor…

psychiatryemergency medicinecommunicationsystemolanzapine
QLDhospital2026-05-07

Non-inquest findings into the death of Lucy Campbell

0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…

Lucy Margaret Campbell died eight days after birth from severe hypoxic ischemic encephalopathy following complicated assisted vaginal birth at Ingham Hospital. Her mother had a low-risk pregnancy complicated by spontaneo…

obstetricsmidwiferydiagnosticcommunicationoxytocin
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
WA2026-04-28

Inquest into the Death of Corey Desmond DEVREE

41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…

Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…

psychiatrygeneral practicediagnosticcommunication
QLD2026-03-31

Inquest into the death of Kyle James Gallagher

22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…

Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…

ENT surgeryradiologydiagnosticcommunicationdiazepam
QLDhospital2026-03-31

Inquest into the death of Robyn Ann Beale

78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …

A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…

general surgeryanaesthesiadiagnosticcommunicationoxycodone
WAhospital2026-03-26

Inquest into the Death of Sandipan DHAR

1y · Male·Complications of acute lymphoblastic leukaemia

Sandipan Dhar, 21 months old, died from undiagnosed acute lymphoblastic leukaemia (ALL) complicated by sepsis and pneumonia on 24 March 2024. After three weeks of intermittent fever, he attended his GP three times and wa…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
NSWhospital2026-03-19

Inquest into the death of Eve Brown

42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…

Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…

emergency medicinegeneral practicediagnosticcommunicationceftriaxone
VIChospital2026-03-13

Finding into death of Wayne Ronald Watson

61y · Male·Intracranial haemorrhage and myocardial infarct

A 61-year-old man with extensive cardiac disease collapsed at a supermarket, striking his head and losing consciousness for less than 10 seconds. Paramedics identified STEMI and administered heparin on advice from Austin…

cardiologyemergency medicinediagnosticcommunicationheparin
VIChospitalPodcast2026-02-20

Finding into death of James Harilaos Tsindos

17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis

James Tsindos, a 17-year-old with known nut allergy and mild asthma, experienced anaphylaxis after inadvertently ingesting cashews in a vegan restaurant meal on 27 May 2021. Ambulance paramedics administered two doses of…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline (epinephrine) intramuscular
VIChospital2026-02-05

Finding into death of Max Peter McKenzie

15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…

Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…

emergency medicineparamedicinedelaycommunicationadrenaline
NSWhospital2026-01-13

Inquest into the death of Paul Harris

43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…

Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …

general practiceemergency medicinediagnosticcommunicationceftriaxone
NThospital2026-01-09

Inquest into the death of C Guyula

49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …

A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical fa…

anaesthesiasurgeryproceduralmedicationfentanyl
WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…

psychiatryintensive caresystemdelayaripiprazole depot
NThospital2025-12-19

Inquest into the death of T. Ptjara and T. Ptjara

Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…

Two Aboriginal brothers with chronic alcohol use disorder and cognitive impairment died in July and September 2023 in Alice Springs Hospital. Both had adult guardianship orders, NDIS packages, and aged care assessments r…

emergency medicineintensive carecommunicationsystem
NSWhospital2025-12-08

Inquest into the death of Katrina McGrady

43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm

Trina McGrady, a 43-year-old Goomeroi woman, died from subarachnoid haemorrhage due to a ruptured berry aneurysm on 15 September 2020. She had been admitted to John Hunter Hospital following incidental discovery of two l…

neurosurgeryradiologycommunicationdiagnosticaspirin
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