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VIChospital2025-06-25

Finding into death of RFV

87y · Male·Consequences of an assault with severe facial fractures

RFV, an 87-year-old man, died from severe facial fractures and traumatic brain injury sustained during an assault by his daughter-in-law. He presented to hospital in critical condition with cardiac arrest, multiple facia…

emergency medicineintensive caresystem
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
TASaged care2025-05-26

Coroner's Finding: de-identified GJ

94y · Male·aspiration pneumonia due to stroke following surgery to repair fracture of neck …

A 94-year-old man with dementia died from aspiration pneumonia following a stroke after hip surgery. The stroke and hip fracture resulted from being pushed by another resident with Alzheimer's dementia at an aged care fa…

geriatric medicineorthopaedic surgerysystemdelayoxazepam
WAhospital2025-04-17

Inquest into the Deaths of HC and Child HR

terminal palliative care in a girl with a clinical diagnosis of aspiration pneum…

A 12-year-old girl with severe cerebral palsy (quadriplegia) died from aspiration pneumonia whilst in state care following removal from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence,…

paediatricspalliative care
ACThospital2025-04-09

Inquest Into The Death Of Peter Hanisch

69y · Male·thoracic aortic aneurysm with dissection

Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…

radiologyemergency medicinediagnosticsystem
NTcommunity2025-04-04

Inquest into the death of Kailab

15y · Male·multiple injuries caused by a motor vehicle accident

Kailab Moir, a 15-year-old Aboriginal boy with FASD, complex trauma, and ADHD, died in a single-vehicle rollover while a passenger in a stolen vehicle. He had been in out-of-home care since age 5 with approximately 35 di…

paediatricspsychiatrydiagnosticsystemalcohol
NSW2025-02-28

Inquest into the death of Cameron De Vries

20y · Male·Drowning precipitated by a seizure

Cameron De Vries, a 20-year-old man with severe autism spectrum disorder and global developmental delay, died by drowning precipitated by a seizure in a bathtub at a disability support home. He had experienced a seizure …

emergency medicineneurologydiagnosticsystemranitidine
VIChome2025-02-27

Finding into death of Shayn Nathan Darmanin

43y · Male·Mixed drug toxicity (methadone, synthetic cannabinoids (5f-cumyl-pinaca and cumy…

Shayn Darmanin, a 43-year-old man with epilepsy, died from mixed drug toxicity involving methadone, synthetic cannabinoids, olanzapine, and duloxetine. He had a significant history of substance abuse, family violence off…

toxicologypsychiatrymethadone
ACThospital2025-02-26

Inquest Into The Death Of Jessica Hilary Bovill

43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…

A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…

emergency medicinetoxicologymedicationcommunicationamitriptyline
VIChome2025-01-28

Finding into death of Edward Grant Harris

18y · Male·Heroin toxicity

Edward Grant Harris, an 18-year-old with autism spectrum disorder, ADHD, and borderline intellectual function, died from heroin toxicity in his supported accommodation. He had a complex history of behavioural challenges,…

paediatricspsychiatrysystemheroin
VIChome2024-12-16

Finding into death of Geoffrey Paul McConachy

82y · Male·Incised injury to right leg

Geoffrey McConachy, 82, died by suicide on 18 September 2023 following a stroke in late 2022 that caused speech impairment and severe depression. He explicitly expressed suicidal ideation and requested information about …

psychiatrygeneral practicecitalopram
TASaged care2024-11-18

Coroner's Finding: Bradburn, Lester Basil

73y · Male·Traumatic head, facial and chest injuries caused by fall down stairs at resident…

A 73-year-old man with Parkinson's disease and recent falls died from traumatic injuries after falling down six stairs while exiting a residential aged care facility at 5:00 AM. He had been admitted only 10 days prior an…

geriatric medicineneurologysystemcommunication
QLDhospital2024-10-18

Findings into the death of John Ainsworth

68y · Male·Cerebrovascular disease

John Raymond Ainsworth, a 68-year-old prisoner, died of cerebrovascular disease following a severe stroke on 25 November 2020. He had poorly controlled Type II diabetes, hypertension, and high cholesterol. Prior to his a…

neurologyemergency medicinedelaymetformin
NSWhospital2024-10-11

Inquest into the death of AX

45y · Female·Multiple blunt force injuries

A 45-year-old woman with acute psychotic illness attended Prince of Wales Hospital ED on 4 August 2020 after presenting to police with persecutory delusions. She was assessed by mental health and medical clinicians who a…

emergency medicinepsychiatrydiagnosticcommunication
VIChospital2024-10-07

Finding into death of Danielle Julie Kaye Thomson

41y · Female·Neck compression and hanging

Danielle Thomson, a 41-year-old woman with complex medical and mental health conditions including cervical dystonia, bipolar disorder, borderline personality disorder, chronic pain, and alcohol use disorder, died by suic…

psychiatryaddiction medicinecommunicationsystembuprenorphine
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
VIChospital2024-07-23

Finding into death of Laurence Maxwell Attwood

68y · Male·Ischaemic infarction of the right cerebral hemisphere and cerebellum due to thro…

A 68-year-old man died from ischaemic stroke (basilar artery and right posterior cerebral artery thrombosis) seven days after being struck by a motor vehicle while attempting to cross Warrigal Road, Hughesdale. The colli…

trauma surgeryneurosurgerysystem
VICcommunity2024-07-18

Finding into death of Frankie Skye Foulkes

0y · Female·Complications of spinal muscular atrophy

Frankie Skye Foulkes, a four-month-old diagnosed with spinal muscular atrophy type 1, died from complications of SMA while positioned in a standard car seat during a car journey. She had recently commenced nusinersen tre…

neurologyoccupational therapysystemnusinersen
QLD2024-06-18

Inquest into the deaths of Shiralee Deanne Tilberoo and Vlasta Wylucki

Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…

Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…

cardiologyaddiction medicineproceduralcommunicationdiazepam
VIChome2024-05-20

Finding into death of Gwyn Pugh

63y · Male·Incised injuries to the neck and upper limbs

Gwyn Pugh, a 63-year-old man with longstanding bipolar affective disorder, died by suicide on 26 October 2022. He had been hospitalized for depression in April-May 2022 and received electroconvulsive therapy. Post-discha…

psychiatrygeneral practicecommunicationsystemmirtazapine

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