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NSWhome2025-06-24

Inquest into the death of Jade

3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…

Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…

paediatricspsychiatrydiagnosticcommunicationquetiapine
VIChome2025-06-24

Finding into death of Jessica Geddes

27y · Female·Complications of multiple blunt force injuries

Jessica Geddes, 27, was killed by her partner Robert Rickerby through multiple blunt force injuries on 6 November 2020. The autopsy revealed extensive acute, subacute and chronic injuries inconsistent with accidental tra…

general practicepsychiatrydiagnosticsystemmethamphetamine
TAShome2025-06-24

Coroner's Finding: Infant W and Infant P

Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…

Two premature infants died from unsafe sleeping environments while in the care of their parents, despite being subject to child protection notifications. Infant W (4 months) died from asphyxia due to accidental overlay i…

paediatricspsychiatrydiagnosticcommunicationmethadone
QLDhospital2025-06-20

Inquest into the death of Christopher Glen Essery

74y · Male·Sepsis secondary to fistulating Crohn's disease and post-surgery complications f…

Christopher Essery, a 74-year-old man with complex fistulating Crohn's disease, died from sepsis following surgery on 24 January 2019. He was transferred to Princess Alexandra Hospital (PAH) on 31 August 2018 for special…

colorectal surgerygastroenterologysystemcommunication
TASPodcast2025-06-19

Coroner's Finding: Findings in relation to Shane Navin, Leigh Mundy, Dennis Neagle and Anthony Seymour

Multiple causes: Shane Navin - drowning; Leigh Mundy and Dennis Neagle - multipl…

A comprehensive coronial inquest into four deaths at Targa Tasmania motorsport events (2021-2022). Shane Navin drowned after his vehicle crashed into a creek; Leigh Mundy and Dennis Neagle died in a high-speed crash due …

diagnosticsystemmirtazapine
NSWhome2025-06-18

Inquest into the death of Hillal Barbour Interlocutory Application Decision

Male·Gunshot wounds to the chest and lower abdomen

Hillal Barbour died from gunshot wounds sustained during a police response to a 000 call reporting welfare concerns. Officers responded to reports that Hillal was holding a shovel and following his mother. When police ar…

paramedicine
VICcommunity2025-06-18

Finding into death of Ying Sun

53y · Female·Drowning

Ying Sun, 53, drowned at Cape Schanck after being swept off rocks by unexpected large waves while visiting Australia with her spouse and son. She was struck by two successive waves, knocked into the water, and despite re…

QLD2025-06-18

Inquest into the deaths of Anthony Michael Charlwood and Krystal Renee Evans

Multiple injuries due to motor vehicle collision

Two persons died following a high-speed motorcycle crash while evading police interception. Anthony Charlwood (36) and Krystal Evans (35) collided with a light pole at high speed on Helensvale Road. The motorcycle was be…

amphetamine
TAShospital2025-06-17

Coroner's Finding: de-identified RS

68y · Male·Exsanguination due to peptic ulcer of the duodenum with erosion into the gastrod…

A 68-year-old man presented to the emergency department with two episodes of fresh rectal bleeding and elevated blood urea. Despite stable vital signs, he was discharged after two hours with haemorrhoid suppositories and…

emergency medicinegastroenterologydiagnosticdelay
TASaged care2025-06-16

Coroner's Finding: McDonald, Maureen June

87y · Female·Terminal exacerbation of chronic obstructive pulmonary disease; antecedent cause…

Maureen 'Kitty' McDonald, 87, died from terminal exacerbation of COPD with an antecedent sacral pressure wound infection. She was admitted to residential aged care in October 2020 with a stage-two sacral pressure injury …

geriatric medicinegeneral practicesystemcommunicationantibiotics
TASaged care2025-06-13

Coroner's Finding: de-identified OQ -2

84y · Male·Head injury - left lateral convexity acute subdural haematoma with 2mm midline s…

An 84-year-old man with Parkinson's disease and moderate dementia was admitted to a rehabilitation unit after a fall at an acute hospital. He had been assessed as high falls risk and required a patient sitter at the acut…

geriatric medicinerehabilitation medicinecommunicationsystem
ACTPodcast2025-06-13

Inquiry Into The Orroral Valley Fire

On 27 January 2020, an ADF MRH-90 Taipan helicopter ignited a fire in Namadgi National Park, ACT, during Defence Assistance to the Civil Community operations. The crew made an unplanned landing in the high-danger Orroral…

communicationsystem
VIChome2025-06-12

Finding into death of Monique Anita Lezsak

39y · Female·Multiple stab wounds

A 39-year-old woman was fatally stabbed by her partner following relationship separation. The victim had ended the relationship after her partner exhibited escalating coercive and controlling behaviour throughout their r…

SAhospital2025-06-12

Coroner's Finding: Salter, Kathleen Ethel

76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy

A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the com…

general surgeryanaesthesiadiagnosticproceduralapixaban
WA2025-06-12

Inquest into the Death of Sam Phillip Chisholm LYNCH

27y · Male·effects of fire

Sam Lynch, aged 27, died from effects of fire while in remand at Hakea Prison on 5 March 2024. Following a dispute over undelivered canteen items, Sam set his mattress ablaze with a lighter. The response was catastrophic…

systemcommunicationdiazepam
WAcommunity2025-06-09

Inquest into the Death of Joyce Gladis CLARKE

29y · Female·gunshot wound to the abdomen

29-year-old Aboriginal woman (JC) of Ngarlawangga Yamatji Martu descent died from a gunshot wound inflicted by police on 17 September 2019. Four days prior, she was appropriately discharged from Sir Charles Gairdner Hosp…

psychiatryemergency medicinesystemmethamphetamine
VIC2025-06-06

Finding into death of Cienna Ros'Se Jervies

12y · Female·Drowning

Cienna Ros'Se Jervies, a 12-year-old local resident, drowned at Ocean Grove Beach on 19 September 2023 in treacherous conditions with strong rips and large waves. She became separated from companions while swimming near …

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
SA2025-06-03

Coroner's Finding: Sears, James Frank

53y · Male·disseminated malignant melanoma

A 53-year-old man died of disseminated malignant melanoma while incarcerated at Yatala Labour Prison. Initial excision of a large arm mole in November 2019 revealed Stage III melanoma. A January 2020 multi-disciplinary t…

dermatologyoncologycommunicationsystemdabrafenib
VIChospital2025-06-02

Finding into death of Julie Elizabeth Bruton

58y · Female·Aspiration pneumonia in association with rapidly progressive frontotemporal deme…

Julie Bruton, aged 58, died from aspiration pneumonia associated with rapidly progressive frontotemporal dementia and malnourishment. She was admitted to hospital on 17 December 2023 with acute respiratory distress and d…

palliative caregeriatric medicine

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