Coronial
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VIChospitalNew2026-07-01

Finding into death of HJW

69y · Female·Urosepsis secondary to anuric acute renal failure and corona radiata infarct; co…

A 69-year-old diabetic woman presented to Maroondah Hospital Emergency Department on 9 June 2024 with severe right-sided abdominal pain and vomiting. CT imaging at 10:00am confirmed emphysematous pyelitis (gas-forming ki…

emergency medicinegeneral medicinediagnosticdelayfentanyl
SAhospital2026-05-28

Coroner's Finding: Sargeant, Gary Dale

36y · Male·Drowning

Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…

general medicinepsychiatrydiagnosticprocedural
VICcommunity2026-05-07

Finding into death of Elizabeth Susan Edwina Ferris

44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…

Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…

psychiatryintensive carediagnosticcommunicationheroin
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
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
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
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
SAhospital2026-03-30

Coroner's Finding: Chadha, Hemant and Battagodage, Sachintha Nandula

Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…

Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…

emergency medicinegeneral practicediagnosticcommunicationdiazepam
WA2026-03-26

Inquest into the Death of Brian John KEALY

42y · Male·Ligature compression of the neck (hanging)

Brian Kealy, aged 42, died by suicide via hanging at Hakea Prison on 2 August 2024 while on remand. He had complex mental health needs including probable schizophrenia, anti-social personality disorder, and polysubstance…

psychiatrygeneral medicinecommunicationsystemolanzapine
NSWhospital2026-03-25

Inquest into the death of Lifa Faafete

69y · Male·advanced cholangiocarcinoma

Mr Lifa Faafete, aged 69, died from advanced cholangiocarcinoma while in remand custody at Metropolitan Special Programs Centre. He was appropriately transferred to Prince of Wales Hospital on 22 March 2025 for symptom m…

palliative careoncologycommunication
WA2026-03-09

Inquest into the Death of Russell Graham PENNY

56y · Male·complications of viral hepatitis related advanced-chronic liver disease

Russell Graham Penny, 56, a Noongar man, died from advanced liver disease with hepatocellular carcinoma while in prison custody. With chronic hepatitis C from intravenous drug use, Russell had developed cirrhosis and was…

correctional healthgeneral medicinesystemcommunication
VIChospital2026-02-27

Finding into death of PDR

78y · Male·Acute pancreatitis

A 78-year-old man with a long history of mental illness and multiple chronic physical conditions died from acute pancreatitis on 12 May 2025, nine days after presenting with nausea and vomiting at Thomas Embling Hospital…

emergency medicinepsychiatryolanzapine
TAShospital2026-02-24

Coroner's Finding: Bradley, Steven Basil

65y · Male·Acute on chronic subdural haematoma caused by accidental falls

Steven Basil Bradley, 65, died from acute on chronic subdural haematoma following an unwitnessed fall in hospital. He had metastatic prostate cancer, ischaemic heart disease, and diabetes. On admission for chest sepsis, …

oncologygeneral medicinesystemdelay
VIChospital2026-02-20

Finding into death of Brian Robert Dean

44y · Male·Sepsis due to Streptococcus pyogenes (Group A Streptococcus) septicaemia complic…

Brian Dean, a 44-year-old with obesity, presented to hospital on 1 July 2023 with influenza A and signs of shock (tachycardia, hypotension, elevated lactate). He was treated with fluids and discharged the next morning ap…

emergency medicineinfectious diseasesdiagnosticdelayondansetron
SAaged care2026-02-12

Coroner's Finding: D Angelo, Adelina

88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…

An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatra…

general practicegeriatric medicinediagnosticcommunicationfurosemide
TAShome2026-01-22

Coroner's Finding: Kerrie Dawn Grant

72y · Female·acute on chronic renal failure due to sepsis and chronic left leg cellulitis

Kerrie Dawn Grant, a 72-year-old woman with multiple comorbidities including pulmonary hypertension, cardiac failure, COPD, and myelofibrosis, had a well-documented history of recurrent falls with prolonged periods unabl…

general medicinecardiologydischargecommunication
WA2026-01-08

Inquest into the Death of Lewis Walter WARD

Male·out-of-hospital cardiac arrest due to atherosclerotic cardiovascular disease and…

Lewis Walter Ward, a Ngarinyin man in his early thirties, died from out-of-hospital cardiac arrest while playing sport at West Kimberley Regional Prison. He had Type 2 diabetes, hypertension, dyslipidaemia, and was a smo…

cardiologyemergency medicinediagnosticsystem
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
NSW2025-12-08

Inquest into the death of Benjamin Cullen

41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…

Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from P…

neurologyemergency medicinemedicationsystemlevetiracetam
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