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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
VIChospital2026-01-08

Finding into death of Malakai Cross-De Jesus

<1y · Male·Complications following forceps delivery

A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
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
QLDhospital2025-10-24

Non-Inquest findings into the death of Ms G

76y · Female·Head injury comprised of subdural haematoma, subarachnoid haemorrhage with brain…

A 76-year-old woman died from complications of a severe head injury sustained in a motor vehicle collision. She was initially managed conservatively at a regional hospital, but her condition deteriorated markedly at 9pm …

neurosurgeryemergency medicinecommunicationdelay
VIChospital2025-09-30

Finding into death of Robert Thoai Dao

73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…

A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…

paramedicineemergency medicinediagnosticprocedural
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
VIChospital2025-06-03

Finding into death of DRF

95y · Female·Acute intracranial haemorrhage

DRF, a 95-year-old woman with dementia, hearing impairment, mobility limitations, and mild cognitive impairment, died from acute intracranial haemorrhage following blunt head trauma. She had been living with her son UJN,…

geriatric medicineneurosurgerycommunicationsystemwarfarin
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…

emergency medicineintensive carediagnosticproceduralhydromorphone
TAShospital2025-04-29

Coroner's Finding: de-identified OQ

41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…

A 41-year-old woman died from frontal lobe ischaemic infarcts caused by cerebral vasospasm complicating subarachnoid haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days wit…

emergency medicineneurosurgerydiagnosticcommunicationchlorpromazine
WAcustody2025-04-10

Inquest into the Death of Dannielle Stacey LOWE

41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm

Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…

emergency medicineneurosurgerydiagnosticcommunicationparacetamol
NSWaged care2025-01-28

Inquest into the Death of Robert Driver

89y · Male·Cervical spine trauma

Robert Driver, 89, died from cervical spine trauma sustained after being struck by another dementia-affected resident in an aged care facility. He was assessed overnight at the facility and transferred to hospital the fo…

emergency medicineneurosurgerydelaycommunicationrisperidone
NSWhome2025-01-17

Inquest into the death of BG

<1y · Male·Concussive brain injury

A 7-month-old boy died from concussive brain injury caused by intentional head trauma inflicted by his mother's partner in a domestic violence context. The child had multiple bruises, bite marks, and subdural haemorrhage…

forensic medicinepaediatricssystemcommunication
VIC2024-12-16

Finding into death of Caroline Monique Hall

52y · Female·Spinal injuries sustained in falls in a woman with multiple medical comorbiditie…

Caroline Monique Hall, a 52-year-old woman with intellectual disability, epilepsy, schizophrenia, and multiple comorbidities living in supported disability accommodation, died from spinal injuries sustained in falls. She…

general practiceemergency medicinediagnosticdelaymorphine
TAShospital2024-10-18

Coroner's Finding: Long, Leonard

73y · Male·subdural haematoma from fall

Leonard Athol Long, a 73-year-old on warfarin for mechanical mitral valve replacement, fell twice during hospitalization for urinary tract infection. He was on SMZ-TMP antibiotics, which interact significantly with warfa…

general medicineemergency medicinediagnosticsystemwarfarin
VICPodcast2024-09-19

Finding into death of George Diamond

18y · Male·complications of acute on chronic subdural haemorrhage (operated) in the setting…

George Diamond, 18, died from acute-on-chronic subdural haemorrhage sustained during boxing sparring on 18 February 2019. He had suffered a head injury during sparring on 25 October 2018, presenting with headache, nausea…

general practiceemergency medicinediagnosticdelayparacetamol
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
WAcustody2024-06-12

Inquest into the Death of Alf Deon EADES

46y · Male·head injury complicated by bronchopneumonia, with palliation

A 46-year-old remand prisoner died from traumatic brain injury sustained during a severe prison assault. Critical failures in responding to cell call alarms preceded the attack. Prison officers answered multiple distress…

correctional healthneurosurgerycommunicationsystem
TAShospital2024-03-27

Coroner's Finding: Leary, Kane

17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…

Kane Mathew Leary, 17, died from a stroke (left middle cerebral artery infarction) following a motorbike collision. The critical clinical lesson involves a missed diagnosis of left internal carotid artery dissection on i…

emergency medicineneurosurgerydiagnosticcommunicationmorphine
WAcustody2024-02-21

Inquest into the Death of Iain Campbell BUCHANAN

65y · Male·complications, including pneumonia, of traumatic brain injury

A 65-year-old male prisoner died from complications of severe traumatic brain injury sustained when punched by another prisoner at Hakea Prison. He fell backwards, striking his head, and was assessed at the prison medica…

neurosurgeryemergency medicinedelaysystem
VIChome2024-01-16

Finding into death of Kieran Joseph McGuinness

37y · Male·Sudden unexpected death in epilepsy (SUDEP) in the setting of acquired brain inj…

Kieran McGuinness, 37, died of sudden unexpected death in epilepsy (SUDEP) following acquired brain injury with post-traumatic epilepsy. He was found unresponsive on his apartment floor on 11 September 2022, having been …

neurosurgeryneurologydiagnosticcommunicationlevetiracetam

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