Coronial
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VICcommunityNew2026-08-25

Finding into death of Garry William Ledger

78y · Male·Complications of acute renal impairment in the setting of pelvic and lumbar frac…

Garry Ledger, 78-year-old South Australian visitor, died three weeks after falling on a Melbourne tram on 28 August 2025. While boarding tram route 16, he fell during tram acceleration while using his Myki card and befor…

trauma surgerygeriatric medicinewarfarin
VICcommunityNew2026-08-17

Finding into death of Guy Christian Mason

48y · Male·Pulmonary thromboembolism

Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…

emergency medicinegeneral surgerydiagnosticsystemenoxaparin
SAhome2026-08-12

Coroner's Finding: Sylvia, Kate Marie

32y · Female·cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage

Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. mis…

paramedicinegeneral medicinediagnosticcommunicationoral contraceptive pill
ACThome2026-08-03

Inquest into the death of Felipe Esteban Alvarez (No 2)

Male·toxicity caused by a combination of methylamphetamine and morphine

Felipe Esteban Alvarez died on 30 March 2021 from toxicity caused by methylamphetamine and morphine (heroin) ingestion at his unit in Taylor, ACT. He collapsed after self-injecting heroin in the presence of others, inclu…

addiction medicineemergency medicinedelayproceduralheroin
VICcommunity2026-07-27

Finding into death of DH I

37y · Male·Multiple injuries sustained in a train incident

A 37-year-old Aboriginal man with chronic opioid use disorder and co-occurring mental health issues presented to Royal Melbourne Hospital's Mental Health, Alcohol and Other Drugs Hub after being found slumped in Melbourn…

emergency medicineaddiction medicinesystemheroin
SAhome2026-07-13

Coroner's Finding: Low, David John

64y · Male·ischaemic and hypertensive heart disease (operated) with cardiomegaly with contr…

A 64-year-old man with ischaemic heart disease, cardiomegaly, diabetes and obesity died at home from cardiac failure after calling his care worker for assistance. A paramedic arrived but refused to force entry, instead a…

cardiologyparamedicinesystemdelay
QLDcommunity2026-06-26

Inquest into the death of Wayne Thomas Kerle

68y · Male·Cardiac arrest - unascertained etiology with multiple contributing factors inclu…

Wayne Thomas Kerle, 68, was arrested at his home for cannabis possession. Queensland Ambulance Service paramedics assessed him when he reported respiratory distress but cleared him for police custody after a limited exam…

paramedicineemergency medicinediagnosticproceduraldiazepam
VICcommunity2026-06-19

Finding into death of Agostino Di Clemente

82y · Male·Multiple injuries sustained in a motor vehicle incident (car vs. tree, driver)

An 82-year-old man with recently diagnosed emerging Alzheimer's disease presented to his GP with lower respiratory infection and mild confusion. The GP appropriately arranged hospital admission via family transport. Howe…

general practicegeriatric medicine
QLDhome2026-06-17

Inquest into death of Steven Richard Angus

52y · Male·Gunshot wound to the chest

Steven Richard Angus, a 52-year-old veteran with severe alcohol use disorder, major depressive disorder, and generalised anxiety disorder, died from a gunshot wound inflicted by Queensland Police during a welfare check o…

emergency medicinepsychiatrysystemcommunicationalcohol
TAScommunity2026-05-26

Coroner's Finding: de-identified HK

32y · Female·Unable to be determined

A 32-year-old woman with obesity was prescribed Ozempic 1mg weekly in August 2024 (above the recommended starting dose) for weight management. She developed prolonged gastrointestinal symptoms and took loperamide for dia…

general practiceparamedicinesemaglutide
VIChome2026-04-30

Finding into death of Nick Panagiotopoulos

47y · Male·Acute myocardial infarction due to thrombotic occlusion of the right coronary ar…

Nick Panagiotopoulos, a 47-year-old man, suffered a fatal acute myocardial infarction (heart attack) on 16 October 2021 at home in Preston, Victoria. His family made five calls to Triple Zero (000) requesting emergency a…

cardiologyemergency medicinesystemdelay
WA2026-04-28

Inquest into the Death of Corey Desmond DEVREE

41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…

Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…

psychiatrygeneral practicediagnosticcommunication
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
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
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
SAcommunity2026-03-26

Coroner's Finding: Shepley, Adam Troy

30y · Male·Unascertained; likely cardiac arrhythmia

Adam Troy Shepley, aged 30, died in police custody following restraint after climbing onto roofs while displaying drug-affected and paranoid behaviour. Post-mortem examination revealed an unascertained cause, likely a ca…

emergency medicineparamedicinediagnosticcommunicationmethamphetamine
VIChospital2026-03-25

Finding into death of JNL (Jeremy)

14y · Male·Retroperitoneal haemorrhage secondary to abdominal injuries sustained in a motor…

A 14-year-old boy riding an illegally high-powered e-scooter (capable of 40-50 km/h) collided with a utility vehicle at a residential intersection. The e-scooter exceeded legal speed limits and age restrictions under Vic…

emergency medicinetrauma surgery
NSWcustody2026-03-20

Inquest into the death of Phillip Walton

48y · Male·cardiac arrhythmia which occurred in the context of physical exertion and hypoxi…

Phillip Walton, a 48-year-old with schizophrenia well-managed on clozapine for nearly 20 years, suffered an acute psychotic episode likely precipitated by cannabis use at a circus. After aggressive behaviour requiring po…

emergency medicineparamedicinediagnosticcommunicationclozapine
VIChome2026-03-19

Finding into death of Aisha Natasha Khan

44y · Female·Mixed alcohol and drug toxicity (tapentadol, diazepam, mirtazapine, amitriptylin…

Aisha Natasha Khan, 44, died from mixed alcohol and drug toxicity following an intentional polypharmacy overdose with alcohol consumption. She had a history of depression, alcohol use disorder, chronic pain, and two prio…

psychiatryemergency medicinesystemdelaytapentadol
VICcommunity2026-03-04

Finding into death of Anthony Laurence Parisi

39y · Male·Multidrug toxicity (GHB, methylamphetamine, ketamine) in a setting of restraint …

Anthony Parisi, 39, died from multidrug toxicity (GHB, methamphetamine, ketamine) in a setting of police restraint and moderate coronary artery atherosclerosis. He consumed large quantities of GHB and methamphetamine on …

emergency medicineintensive caregamma-hydroxybutyrate
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