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VICcommunity2026-01-08

Finding into death of Dominic Joshua Clifford

23y · Male·Plastic bag asphyxia in setting of irrespirable atmosphere induced by nitrogen g…

Dominic Joshua Clifford, a 23-year-old with a complex history of mental illness including depression, anxiety, ADHD, and likely autism spectrum disorder, died by nitrogen gas inhalation in September 2024. He had multiple…

psychiatryfluoxetine
VIChospital2026-01-08

Finding into death of Linette Ann Hawkins

80y · Female·Injuries sustained in a motor vehicle collision (driver)

An 80-year-old woman died from injuries sustained in a motor vehicle collision after likely experiencing a seizure or similar medical episode while driving. She had a history of traumatic brain injury from 1972 and a doc…

neurologytrauma surgerycommunicationsystemlevothyroxine
TAShome2026-01-07

Coroner's Finding: de-identified UN

43y · Male·hypoxic brain injury caused by cardiac arrest due to unintentional drug poisonin…

A 43-year-old man with long-standing opioid use disorder and polysubstance dependence died from hypoxic brain injury following cardiac arrest caused by drug poisoning. He had been prescribed large quantities of pregabali…

general practiceemergency medicinemedicationdiagnosticmethadone
TASaged care2026-01-07

Coroner's Finding: Bird, Allan Roy

92y · Male·Consequences of accidental fall at RACF: post-operative delirium, left femoral i…

A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner ident…

geriatric medicineorthopaedic surgerydiagnosticsystembenzodiazepine
VIChome2026-01-06

Finding into death of Michelle Margaret Darragh

32y · Female·Stab wound to the back extending into the posterior neck, causing subtotal trans…

Michelle Darragh, a 32-year-old social worker, was fatally stabbed by her former partner Benjamin Coman on 9 October 2021. She was pregnant with their third child. The relationship involved progressive coercive control, …

psychiatryemergency medicinediagnosticcommunicationsertraline
WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…

psychiatryintensive caresystemdelayaripiprazole depot
WAhome2025-12-22

Inquest into the Death of Child LK (Name Subject to Suppression Order)

14y · Male·epilepsy in a boy with Influenza B and COVID-19 infections

Child LK was a 14-year-old Aboriginal boy in state care who died suddenly on 24 August 2023 from an unwitnessed epileptic seizure precipitated by concurrent Influenza B and COVID-19 infections. He had been diagnosed with…

paediatricsemergency medicinecommunicationsodium valproate
NSWhospital2025-12-19

Inquest into the death of JBO

27y · Female·Cardiac arrhythmia (first confirmed as ventricular fibrillation) of unascertaine…

A 27-year-old Aboriginal woman suffered sudden cardiac arrhythmia (ventricular fibrillation) immediately after recording video evidence of a suspected breach of her protective apprehended personal violence order (APVO). …

emergency medicinecardiologycommunicationsystemamiodarone
VIChome2025-12-19

Finding into death of Narisha Faye Cash

41y · Female·Combined Drug Toxicity (ethanol and benzodiazepine)

Narisha Faye Cash, 41-year-old Aboriginal woman, died on 26 March 2020 from combined drug toxicity (ethanol and benzodiazepines) following an inadequate emergency services response to her mental health crisis. She called…

emergency medicinepsychiatrysystemcommunicationalcohol
NThospital2025-12-19

Inquest into the death of T. Ptjara and T. Ptjara

Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…

Two Aboriginal brothers with chronic alcohol use disorder and cognitive impairment died in July and September 2023 in Alice Springs Hospital. Both had adult guardianship orders, NDIS packages, and aged care assessments r…

emergency medicineintensive carecommunicationsystem
VIC2025-12-18

Finding into death of Chao Liang Mai

56y · Male·Hanging

Chao Liang Mai, a 56-year-old remanded prisoner with documented psychiatric history and previous suicide/self-harm risk flags, died by hanging in a prison cell on 27 November 2018. Critical systemic failures included: (1…

psychiatryemergency medicinesystemcommunication
WA2025-12-17

Inquest into the Death of Child RK (Name Subject to Suppression Order)

14y · Female·ligature compression of the neck (hanging)

Child RK, aged 14, died by suicide while in Department of Communities care at a therapeutic residential group home on 20 April 2022. She had Complex PTSD from childhood trauma and presented multiple times to emergency de…

paediatricsgeneral practicecommunicationsystemmelatonin
WA2025-12-17

Inquest into the Death of Jamie Frederick GINN

50y · Male·cocaine toxicity

Jamie Frederick Ginn, 50, died from cocaine toxicity on 10 October 2023 while in custody at Perth Watch House (PWH). He had ingested approximately one teaspoon of cocaine hydrochloride; the coroner could not determine wh…

systemcocaine
NSWhome2025-12-17

Inquest into the death of MQ

55y · Female·acute necrotising bronchopneumonia

MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…

general practiceemergency medicinediagnosticdelay
NSW2025-12-16

Inquest into the disappearance and suspected death of Cenzig Sarac

24y · Male·The available evidence does not allow for any finding to be made as to the cause…

Cengiz Sarac, aged 24, disappeared on 5 August 2005 and is presumed dead. The Deputy State Coroner found on the balance of probabilities that he died on or shortly after 2 August 2005, based on extensive signs of life in…

VICmental health2025-12-11

Finding into death of Tania Louise De Jong

48y · Female·Mixed drug toxicity (morphine, codeine, venlafaxine, amitriptyline and zopiclone…

A 48-year-old woman with depression, anxiety, and bipolar disorder died from mixed drug toxicity while on voluntary inpatient psychiatric admission. She had undisclosed significant illicit drug use, which was not identif…

psychiatrygeneral practicesystemcommunicationmorphine
WAcommunity2025-12-09

Inquest into the Suspected Death of Eric Donald BRANDRICK

47y · Male·unascertained

Eric Donald Brandrick, aged 47, disappeared from his home in North Fremantle, Western Australia, after 31 December 1989. He had suffered a severe stroke in September 1988 causing left-sided paralysis, visual impairment, …

emergency medicinegeneral medicine
NSWcommunity2025-12-09

Inquest into the deaths of Lynette Thompson and Alan Fletcher

58y · Female; male·Lynette: Thermal injuries (extensive burns) and complications thereof; Alan: Nec…

Two related deaths from domestic violence murder-suicide. Lynette Thompson (58, Aboriginal woman) died from severe burns inflicted by her partner Alan Fletcher (59) on 8 November 2020; Alan subsequently died by hanging. …

communicationsystempetrol
TAShospital2025-12-09

Coroner's Finding: de-identified EM

76y · Female·sepsis as a result of myocarditis and tricuspid valve endocarditis (infective en…

A 76-year-old woman with vascular dementia and emphysema was admitted with sepsis of unknown origin, treated with antibiotics, and discharged after 12 days with improving symptoms. She re-presented 14 days later with rec…

emergency medicinecardiologydiagnosticcommunicationantibiotics
WA2025-12-08

Inquest into the Death of Ashley James BROPHO

Male·Neck injury in a man with atherosclerotic heart disease

Ashley James Bropho, a vulnerable remand prisoner with intellectual impairment, schizophrenia, diabetes, previous myocardial infarction with stent, and atherosclerotic heart disease, was killed on 9 March 2023 at Hakea P…

correctional healthsystem
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