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VIChome2026-04-17

Finding into death of Harrison William Ladd

25y · Male·Combined drug toxicity

Harrison William Ladd, 25, died from combined drug toxicity involving clonazepam, dexamphetamine, codeine, diazepam and pholcodine. He had complex mental health and substance use disorder requiring specialist addiction c…

general practicepsychiatrymedicationcommunicationclonazepam
VIChome2026-04-17

Finding into death of Simon Christopher Gaskill

50y · Male·unascertained

Simon Gaskill, aged 50, was found deceased in sand dunes at Ocean Grove Beach in April 2022 after sleeping rough for months. He had been discharged from hospital in December 2021 following treatment for severe alcohol wi…

emergency medicinegeneral medicinecommunicationsystemalcohol
TAS2026-04-17

Coroner's Finding: de-identified GM

20y · Male·head injuries

A 20-year-old male died from head injuries sustained in a motor vehicle crash while a passenger in a vehicle driven by his friend. The driver, a provisional P2 licence holder, had consumed approximately seven drinks and …

alcohol
VIChospital2026-04-16

Finding into death of Damien Mark Stone

53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures

Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…

emergency medicineneurologydiagnosticcommunicationoxycodone
VICcommunity2026-04-15

Finding into death of LX

31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)

A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …

addiction medicinepsychiatrymedicationsystemmethadone
WA2026-04-14

Inquest into the Death of Wayne HARRIS

56y · Male·complications of advanced metastatic sigmoid adenocarcinoma in an adult man with…

A 56-year-old Aboriginal man died of advanced metastatic sigmoid adenocarcinoma while serving an 11-year sentence for child sex offences. He had been diagnosed with Stage 4 colorectal cancer in 2018 with an expected life…

oncologypalliative carecommunicationsystemchemotherapy
QLDhospital2026-04-14

Inquest into the death of Francis Michael Fahey

70y · Male·Metastatic melanoma with ischaemic heart disease as a contributing condition

Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…

oncologygeneral medicinesystemdelayimmunotherapy
VIChome2026-04-14

Finding into death of James Thomas Reilly

86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall

James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…

emergency medicinegeneral medicinediagnosticmedicationenoxaparin
TASmental health2026-04-13

Coroner's Finding: de-identified DR

41y · Male·asphyxia due to neck compression following ligature suspension (hanging)

DR was a 41-year-old man with bipolar disorder, severe alcohol dependence, and multiple psychosocial stressors including family violence, homelessness, and financial crisis. In October 2023, he presented with acute mania…

psychiatryemergency medicinediagnosticcommunicationolanzapine
NSWcommunity2026-04-10

Inquest into the suspected death of Youliang Lin

84y · Male·The available evidence does not allow for any finding to be made as to the cause…

An 84-year-old man with Alzheimer's dementia and a history of wandering left his home on 15 September 2017 and was never found alive. The coroner determined he is deceased, likely died within days of going missing in bus…

geriatric medicinegeneral practicedelaycommunication
VICcommunity2026-04-09

Finding into death of Bikram Dangol

30y · Male·Head and neck injury in a motorcycle incident

A 30-year-old male motorcyclist died from head and neck injuries sustained in a motorcycle incident on the Western Ring Road on-ramp on 26 July 2018. The coroner found that a water leak from a fire hydrant on VicRoads-ow…

forensic medicinesystemcommunication
NSWcommunity2026-04-08

Inquest into the disappearance and suspected deaths of Nelson and Joshua Chan

Unknown·Cause of death unable to be determined in the absence of post-mortem examination

Nelson Chan (47) and his son Joshua Chan (17) disappeared while rock fishing at Storm Bay, Kiama, NSW on 19 August 2024. Nelson's car was found parked near the fishing location, and Joshua's fishing rod and mobile phone …

ACTcommunity2026-04-08

Inquest into the death of MK

18y · Male·drowning in a motor vehicle accident

MK, 18 years old, died by drowning after his car entered Isabella Pond following a motor vehicle accident. Witnesses observed him inhaling from a balloon-shaped object while driving through a roundabout. A large nitrous …

forensic medicinetoxicologysystemdelaynitrous oxide
WAhospital2026-04-01

Inquest into the Death of David John HATCHER

60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…

David John Hatcher, aged 60, was a remand prisoner at Hakea who died at Fiona Stanley Hospital on 27 September 2024 from pulmonary tuberculosis superimposed on severe chronic obstructive pulmonary disease. He was hospita…

respiratory medicineinfectious diseasesproceduralsystem
NSWhome2026-04-01

Inquest into the death of EJJ

39y · Male·Hanging

A 39-year-old man died by hanging on 16 February 2023 at his home in St Marys, NSW. His mother requested a police welfare check at 8:40pm after he posted a suicide note on Facebook at 2:30pm. Police attended twice (11pm …

psychiatryforensic medicinecommunicationsystemdiazepam
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
WAcommunity2026-03-30

Inquest into the Deaths of Terry James CZERNOWSKI and Lachlan Richard Francis BOWLES

25y · Male·Gunshot injury to the head (Lachlan); gunshot injuries to head and chest (Terry)

On 7 September 2023, 25-year-old Lachlan Richard Francis Bowles shot his 44-year-old workmate Terry James Czernowski at Moylan Grain Silos in Kellerberrin, causing Terry's death from gunshot injuries to the head and ches…

cannabis
NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

This inquest examined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recov…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
VIC2026-03-30

Finding into death of Hari Prasad Dhakal

57y · Male·Neck compression and hanging

A 57-year-old man with schizophrenia and schizoaffective disorder died by hanging in prison on 4 August 2024. He had been receiving antipsychotic treatment via injection (paliperidone) but ceased antipsychotic medication…

psychiatrygeneral practicesystemcommunicationpaliperidone

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