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VIChome2025-07-28

Finding into death of Aluel Ajak

9y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian)

Aluel Ajak, a 9-year-old girl with autism spectrum disorder, severe developmental delay, and moderate intellectual disability, died from injuries sustained when struck by a motor vehicle after absconding from her home. S…

paediatricsdisability medicinesystemdelayclonidine
VIChome2025-07-28

Finding into death of Heather Ida Simone Calgaret

30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…

Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …

general practiceaddiction medicinemedicationdiagnosticbuprenorphine
VIChome2025-07-28

Finding into death of GVY

43y · Female·Head and neck injuries

GVY, aged 43, was fatally attacked by her husband MJN with an axe and knife on 3 December 2022 after she initiated separation. MJN had a documented history of coercive control, physical violence, jealousy, and financial …

systemdelay
VICmental health2025-07-24

Finding into death of Mr SWX

32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity

A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …

psychiatryemergency medicinemedicationcommunicationolanzapine
VICaged care2025-07-24

Finding into death of Silvie Marion Burton

89y · Female·Acute upper airway obstruction by food bolus

An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significant discrepancies between reported actions and actua…

geriatric medicineemergency medicineproceduraldelaycitalopram
NSWcustodial setting (correctional facility) with death at hospital2025-07-23

Inquest into the death of James Cunneen

60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…

James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…

general practiceinfectious diseasesdiagnosticmedicationpantoprazole
VIC2025-07-23

Finding into death of Rachael Lee Dixon

53y · Female·Unascertained

A 53-year-old woman died after consuming psilocybin-containing mushrooms at an unlicensed retreat. She consumed approximately 6 grams of mushroom powder brewed as tea, became unable to walk, reported breathing difficulti…

forensic medicinecardiologysystempsilocybin
WAhome2025-07-23

Inquest into the Death of Lynn Marie CANNON

51y · Female·Multiple sharp force injuries to the chest

Lynn Marie Cannon, 51, was murdered by her estranged husband Paul Cannon on 5 December 2022 at his residence. After ending their 25-year marriage characterised by coercive control, she had begun a new relationship. When …

NSWhospital2025-07-22

Inquest into the death of Prabha Arunkumar

41y · Female·multiple stab wounds to the neck

This inquest examined the death of Prabha Arunkumar, a 41-year-old computer programmer who died from multiple stab wounds to the neck sustained during an attack in Parramatta Park on 7 March 2015. She was transported to …

trauma surgeryvascular surgery
VIChospital2025-07-22

Finding into death of Helena Zoe Broadbent

32y · Female·Head injuries in a motor vehicle incident

Helena Zoe Broadbent, a 32-year-old pregnant Aboriginal woman, died from severe head injuries sustained when her partner William Wilson drove off in a vehicle while she was partially inside it, causing her to be ejected …

emergency medicinetrauma surgerycommunicationsystemcannabis
QLDhospital2025-07-22

Inquest into the death of Hazel Mary Ritchie Brodie

79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…

A 79-year-old woman with severe COPD and heart failure presented with two weeks of nausea and vomiting. She was diagnosed with left ventricular failure (EF 33%) on day 1 of admission. Two cardiologists had key roles: Dr …

cardiologyrespiratory medicinediagnosticcommunicationfurosemide
WAhospital2025-07-22

Inquest into the Death of Samaan Salah Tilmiz ELSAMIN

21y · Male·unascertained

Samaan Salah Tilmiz Elsamin, a 21-year-old with treatment-resistant schizophrenia, moderate-to-severe intellectual disability (IQ 57), and unpredictable violent behavior, died on 9 November 2022 at Joondalup Health Campu…

psychiatryintensive caresystemdelayclozapine
NSWcommunity2025-07-15

Inquest into the disappearance and suspected death of Zac Barnes

18y · Male·unknown - available evidence does not allow for any finding to be made as to the…

This inquest concerns Zac Eran Barnes, an 18-year-old who disappeared on 13 November 2016 from Thornton, NSW, and is presumed deceased. The coroner found on the balance of probabilities that Zac died in suspicious circum…

systemMDMA
VICmental health2025-07-14

Finding into death of Maxwell Bernard Howard

84y · Male·Bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart di…

Maxwell Howard, 84, died from bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart disease while admitted to a mental health acute unit under a Temporary Treatment Order. He had multiple comorbid…

psychiatryemergency medicinecarbamazepine
VIChospital2025-07-14

Finding into death of Nitin Haldipur Prabhu

41y · Male·Head injury in the setting of an e-bicycle collision (rider)

A 41-year-old male cyclist died from severe traumatic head injury following an e-bicycle collision. The coroner found his e-bicycle was unregistered and did not comply with Victorian regulations, exceeding the 250-watt p…

VIChospital2025-07-14

Finding into death of Baby Sidney

0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…

Baby Sidney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell …

obstetricsneonatologydiagnosticcommunicationoxytocin
QLDhospital2025-07-14

Non-inquest findings into the death of a two year old girl whose family was known to Child Safety

2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection

A two-year-old girl died from complications of severe iron-deficiency anaemia and COVID-19 infection. She had significant feeding difficulties, took almost exclusively milk and yoghurt, and was profoundly anaemic with po…

paediatricsemergency medicinediagnosticdelaymethamphetamine
TAS2025-07-14

Coroner's Finding: Penney, Raymond

64y · Male·chest and abdominal injuries due to being crushed by a regrowth tree

Raymond Penney, 64, died when struck by a regrowth tree during mechanical felling operations in a commercial forestry coupe. The old growth tree (68m, 50-60 tonnes) was being felled using excavator-assisted mechanical pu…

occupational and environmental healthproceduralcommunication
VICcommunity2025-07-10

Finding into death of Mr ZLS

34y · Male·Injuries sustained in motor vehicle collision (driver)

A 34-year-old man died in a high-speed motor vehicle collision on 24 August 2023, nine days after purchasing a significantly modified Audi R8. He was driving at approximately 100-111 km/h in a 50 km/h zone when he lost c…

fluoxetine
VIC2025-07-10

Finding into death of Mr JZQ

26y · Male·Injuries sustained in motor vehicle collision (passenger)

A 26-year-old male died as a passenger in a high-speed motor vehicle collision on 24 August 2023. The driver was travelling at approximately 100-111 km/h in a 50 km/h zone on a road known for 'hooning' activity. The vehi…

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