1y · Female·Rapidly developing Streptococcus pneumoniae infection leading to invasive pneumo…
Arianna Maragol, a 16-month-old girl, died from rapidly developing Streptococcus pneumoniae infection leading to invasive pneumococcal disease while in childcare on 24 August 2018. Key clinical lessons emerged: (1) Pneum…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
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…
38y · Female·Multiple injuries sustained when struck by a train
Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…
28y · Male·In keeping with Hanging
A 28-year-old man with a history of depression, anxiety, and previous self-harm died by hanging during a police response to a domestic violence incident. Police attended after his sister reported he had breached an ADVO …
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…
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: (…
45y · Male·Gunshot wounds to the head and left shoulder
Justin Filardo, aged 45, with a 28-year history of schizophrenia, was fatally shot by police after assaulting his sister Bianca in her bedroom. In the weeks prior, Justin had ceased his clozapine medication without clini…
18y · Male·drowning in a motor vehicle accident
MK, 18 years old, died by drowning after his car entered Isabella Pond following a motor vehicle accident. Witnesses observed him inhaling from a balloon-shaped object while driving through a roundabout. A large nitrous …
78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …
A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…
22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…
Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…
Male·Gunshot wounds to the head
This inquest examined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recov…
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…
1y · Male·Complications of acute lymphoblastic leukaemia
A 21-month-old boy died from sepsis secondary to pneumonia complicated by undiagnosed acute lymphoblastic leukaemia (ALL). He presented to ED on 22 March with a three-week history of intermittent fever, had seen three GP…
52y · Male·Complications of chronic cardiac failure in the setting of ischaemic heart disea…
Sacha Timothee Louis Lefebvre, aged 52, died from complications of chronic cardiac failure with ischaemic heart disease and chronic anaemia whilst sleeping rough at Hawthorn Library. He had multiple chronic conditions in…
42y · Male·Ligature compression of the neck (hanging)
Brian Kealy, aged 42, died by hanging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms.…
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…
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…
42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…
Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…
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…
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