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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
WAhospital2026-04-14

Inquest into the Death of Wayne HARRIS

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

Wayne Harris was a 56-year-old Aboriginal man with advanced metastatic sigmoid adenocarcinoma who died in prison custody from complications of his terminal cancer. He was incarcerated for 11 years for child sex offences.…

oncologypalliative carecommunicationsystempalliative chemotherapy
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
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
WAhospital2025-11-27

Inquest into the Death of Stephen Joseph SCHIPP

58y · Male·complications of oesophageal cancer, with terminal palliative care

Stephen Joseph Schipp, a 58-year-old sentenced prisoner, died from complications of oesophageal cancer with terminal palliative care at Bunbury Regional Hospital. He had been diagnosed with oesophageal carcinoma in Janua…

oncologypalliative caresystemdelaychemotherapy
VIChome2025-11-24

Finding into death of Suk Ching Annie Ng

64y · Female·Blunt Force Trauma to the Head in the Setting of Prolonged Lie; Metastatic Breas…

Annie Ng, aged 64, died from blunt force head trauma sustained in her home on 27 February 2024, with death occurring 9 March 2024 at Royal Melbourne Hospital. Her husband Chai, experiencing severe financial and psycholog…

oncologygeneral practicesystem
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
NSWhospital2025-04-16

Inquest into the death of Michael Sanderson

53y · Male·Metastatic pancreatic carcinoma

Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …

general practicepathologydiagnosticcommunicationryzodeg 70/30
NThospital2025-01-10

Inquest into the death of Mati Tamwoy

66y · Male·infectious complications of plasmablastic myeloma

Mati Tamwoy, a 66-year-old Aboriginal man, died in ICU from infectious complications of plasmablastic myeloma after 661 days on remand. He received excellent oncological care including chemotherapy and radiotherapy. Howe…

haematologyoncologysystemcommunicationchemotherapy agents
QLDhospital2024-11-20

Non-inquest findings into the death of Mr W

82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis

An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …

general medicinegeriatric medicinediagnosticcommunicationendone 2.5mg
QLDhospital2024-11-08

Non-inquest findings into the death of SD

61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed

A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…

haematologypathologydiagnosticcommunicationprednisolone
TAShospital2024-09-30

Coroner's Finding: Newell, Warren James

71y · Male·raised intracranial pressure caused by left frontal-temporal-parietal subdural h…

Warren James Newell, a 71-year-old man with oesophageal cancer, presented with acute coronary syndrome on 29 September 2022 and was appropriately diagnosed and treated with anticoagulation and dual antiplatelet therapy. …

cardiologyemergency medicinemedicationsystemenoxaparin
VIChospital2024-09-22

Finding into death of Carl Edward Medlyn

51y · Male·Aspiration pneumonia secondary to traumatic brain injury arising from a scooter …

A 51-year-old man suffered a severe traumatic brain injury in an electric scooter crash on 14 March 2022 and died from aspiration pneumonia on 4 August 2022. He was riding a high-powered scooter (capable of 85km/h) at ex…

neurosurgerytrauma surgerycannabis
WAhospital2024-08-28

Inquest into the Death of Matthew John PICKIN

56y · Male·Complications, including sepsis, of left leg infection (operated), in a man with…

Matthew John Pickin, a 56-year-old prisoner with metastatic lung adenocarcinoma, died from sepsis complicating a left leg infection. His lung cancer was appropriately investigated following haemoptysis in October 2021, w…

respiratory medicineoncologysystemdexamethasone
QLDaged care2024-08-15

Non-inquest findings into the death of Donald Richard Gunthorpe

81y · Male·Carcinoid tumour (metastasis) / metastatic cancer

Donald Richard Gunthorpe, an 81-year-old man with metastatic rectal carcinoma, was appropriately transitioned to end-of-life (palliative) care at a residential aged care facility after hospitalisation for abdominal pain.…

palliative caregeneral practicemedicationdocumentationmorphine
WAhospital2024-08-09

Inquest into the Death of Lindsay WOODS

48y · Male·metastatic high-grade neuroendocrine carcinoma, treated palliatively

Lindsay Woods, a 48-year-old Aboriginal man with chronic paranoid schizophrenia, organic psychosis, and ischaemic heart disease, died from metastatic high-grade neuroendocrine carcinoma. He was subject to a custody order…

psychiatryoncologyclozapine
TAShome2024-08-05

Coroner's Finding: de-identified TJ

82y · Male·Self-inflicted partial contact shotgun wound of the head

An 82-year-old man with recently diagnosed myeloma died by self-inflicted shotgun wound. He had undergone intensive chemotherapy causing significant deterioration in physical health, mental state, and independence. Six w…

oncologygeneral practicecommunicationsystem
WA2024-07-10

Inquest into the Death of Kevin John KEATH

76y · Male·metastatic prostate cancer with terminal palliative care

Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including r…

oncologypalliative caresystemdelay
WA2024-07-10

Inquest into the Death of Jason Anthony THOMPSON

54y · Male·metastatic lung cancer with terminal palliative care

Jason Anthony Thompson, a 54-year-old long-term prisoner at Casuarina Prison, died from metastatic lung cancer. He collapsed on 17 February 2023 with suspected opioid overdose but was not transferred to hospital for appr…

emergency medicineoncologydelaynaloxone
WAhospital2024-04-04

Inquest into the Death of Karl Frederick Dominic HOLMES

66y · Male·Complications of metastatic lung adenocarcinoma, with terminal palliative care, …

Karl Frederick Dominic Holmes, a 66-year-old prisoner with metastatic lung adenocarcinoma and hepatocellular carcinoma, died from complications of his terminal cancer while serving a 7-year sentence. He received excellen…

oncologypalliative caresystemdelaymorphine

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