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QLDcommunityNew2026-06-26

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
VICcommunityNew2026-06-19

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
NSWpolice custody2026-03-20

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
SAhospital2026-02-26

Coroner's Finding: Taylor, Warren Richard

79y · Male·Urinary tract infection with E coli bacteraemia on a background of ischaemic hyp…

A 79-year-old man with multiple comorbidities attended Whyalla Hospital ED following a fall. Paramedics documented concerning vital signs (tachypnoea, tachycardia, low oxygen saturation, fever) and a history suggestive o…

emergency medicinegeneral practicediagnosticcommunicationtrimethoprim
QLDhome2026-02-11

Inquest into the death of FSGT

50y · Male·Gunshot wound to the head

A 50-year-old RAAF Flight Sergeant with Major Depressive Disorder and anxiety died from a self-inflicted gunshot wound to the head after police responded to a domestic disturbance. He had received appropriate, evidence-b…

general practicepsychologysystemcommunicationamitriptyline
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 3

Multiple penetrating knife wounds with hemorrhagic shock and traumatic cardiac a…

On 13 April 2024, Joel Cauchi, with inadequately managed treatment-resistant schizophrenia, stabbed six people to death and injured ten others at Westfield Bondi Junction shopping centre in Sydney. The coroner found Cauc…

emergency medicineparamedicinesystemcommunication
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 1

40y · Male·Victims: fatal stab wounds from knife attack; Joel Cauchi: fatal gunshot wounds …

Joel Cauchi, a 40-year-old man with chronic treatment-resistant schizophrenia, carried out a stabbing attack at Westfield Bondi Junction shopping centre in Sydney on 13 April 2024, killing six people (Dawn Singleton, Jad…

psychiatrygeneral practicecommunicationsystemclozapine
VIChospital2026-02-05

Finding into death of Max Peter McKenzie

15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…

Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…

emergency medicineparamedicinedelaycommunicationadrenaline
QLDhome2026-02-03

Inquest into the death of Bridie Gilligan

42y · Female·Hypoxic brain injury due to choking on food, in a person with Cornelia de Lange …

Bridie Gilligan, aged 42 with Cornelia de Lange Syndrome, profound intellectual disability and dysphagia, died from hypoxic brain injury after choking on a Yumbo burger at her SIL home on 29 April 2021. Her support worke…

speech pathologydieteticscommunicationsystem
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