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VIChospital2026-03-13

Finding into death of Wayne Ronald Watson

61y · Male·Intracranial haemorrhage and myocardial infarct

A 61-year-old man with extensive cardiac disease collapsed at a supermarket, striking his head and losing consciousness for less than 10 seconds. Paramedics identified STEMI and administered heparin on advice from Austin…

cardiologyemergency medicinediagnosticcommunicationheparin
QLDcommunity2026-02-24

Non-inquest findings into the death of Pedro Miguel Ventura Enes

54y · Male·Blunt force head injury due to hit by rock while driving

A 54-year-old Portuguese tourist driving a rental car on the Bruce Highway was struck by a rock that penetrated the windscreen while overtaking a heavy vehicle. The rock, approximately 190mm x 160mm, had become lodged be…

neurosurgerytrauma surgerysystem
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
VIChospital2026-01-08

Finding into death of Linette Ann Hawkins

80y · Female·Injuries sustained in a motor vehicle collision (driver)

An 80-year-old woman died from injuries sustained in a motor vehicle collision after likely experiencing a seizure or similar medical episode while driving. She had a history of traumatic brain injury from 1972 and a doc…

neurologytrauma surgerycommunicationsystemlevothyroxine
VIChospital2026-01-08

Finding into death of Malakai Cross-De Jesus

0y · Male·Complications following forceps delivery

A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
NSWhospital2025-12-08

Inquest into the death of Katrina McGrady

43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm

Trina McGrady, a 43-year-old Goomeroi woman, died from subarachnoid haemorrhage due to a ruptured berry aneurysm on 15 September 2020. She had been admitted to John Hunter Hospital following incidental discovery of two l…

neurosurgeryradiologycommunicationdiagnosticaspirin
VIC2025-10-29

Finding into death of David James Klingberg

55y · Male·Complications of traumatic head injury sustained in a workplace incident (pallia…

David Klingberg, a 55-year-old experienced pile testing engineer, died from traumatic head injury sustained when an auxiliary line hook on a piling rig struck him in the face at a construction site. The hook became jamme…

emergency medicineintensive caresystemmorphine
QLDhospital2025-10-24

Non-Inquest findings into the death of Ms G

76y · Female·Head injury comprised of subdural haematoma, subarachnoid haemorrhage with brain…

A 76-year-old woman died from complications of a severe head injury sustained in a motor vehicle collision. She was initially managed conservatively at a regional hospital, but her condition deteriorated markedly at 9pm …

neurosurgeryemergency medicinecommunicationdelay
SAcommunity2025-10-17

Coroner's Finding: Hall, Robert Lloyd

66y · Male·multiple injuries sustained in motor vehicle collision

A 66-year-old cyclist was struck and killed from behind by a driver with left absolute homonymous hemianopia (left-sided visual field loss) who was not scanning to compensate for his disability. The driver had suffered a…

neurosurgeryneurologysystemcommunication
VIChospital2025-09-30

Finding into death of Robert Thoai Dao

73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…

A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…

paramedicineemergency medicinediagnosticprocedural
NSWhome2025-09-11

Inquest into the death of H GM

0y · Female·Unascertained

A 9-month-old girl died suddenly on 23 July 2018 following multiple head injuries from blunt force trauma sustained shortly before death. She had presented to medical practitioners multiple times in the preceding weeks w…

paediatricsemergency medicinediagnostic
VIChospital2025-07-30

Finding into death of MHT

86y · Male·Complications of blunt force trauma in a man with cardiac amyloidosis and athero…

An 86-year-old man with dementia, cardiac amyloidosis and atherosclerotic cardiovascular disease died from complications of blunt force trauma sustained in an assault by his adult son. The deceased had been diagnosed wit…

emergency medicineneurosurgerysystemcommunicationondansetron
TASaged care2025-06-13

Coroner's Finding: de-identified OQ -2

84y · Male·Head injury - left lateral convexity acute subdural haematoma with 2mm midline s…

An 84-year-old man with Parkinson's disease and moderate dementia was admitted to a rehabilitation unit after a fall at an acute hospital. He had been assessed as high falls risk and required a patient sitter at the acut…

geriatric medicinerehabilitation medicinecommunicationsystem
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…

emergency medicineintensive carediagnosticproceduralhydromorphone
TAShospital2025-04-29

Coroner's Finding: de-identified OQ

41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…

A 41-year-old woman died from frontal lobe ischaemic infarcts caused by cerebral vasospasm complicating subarachnoid haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days wit…

emergency medicineneurosurgerydiagnosticcommunicationchlorpromazine
WAprison2025-04-10

Inquest into the Death of Dannielle Stacey LOWE

41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm

Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…

emergency medicineneurosurgerydiagnosticcommunicationparacetamol
VIChospital2025-03-28

Finding into death of Barbara Anne Deal

86y · Female·Pulmonary thromboembolism in the setting of deep leg vein thrombosis, secondary …

Barbara Deal, 86, died from pulmonary embolism secondary to deep vein thrombosis 17 days after lumbar spinal fusion surgery. Critical failures included: no repeat VTE risk assessments despite policy requirements; inconsi…

neurosurgeryinfectious diseasesmedicationsystemapixaban
TAShospital2025-03-17

Coroner's Finding: Phillips, Helen Lynette

77y · Female·intracranial haemorrhage (subdural, intraventricular and brainstem)

A 77-year-old woman fell from a ladder on 12 December 2022, suffering loss of consciousness and rib fractures. No brain CT scan was performed at Mersey Community Hospital despite the mechanism of injury and unconsciousne…

emergency medicinecardiologydiagnosticdelaythrombolytic agents
VIChome2025-02-14

Finding into death of Martin Barlow

67y · Male·Head injuries sustained in falls

Martin Barlow, 67, died from head injuries sustained in two falls on 5 August 2022 while intoxicated (BAC 0.17 g/100mL). He suffered subarachnoid haemorrhage and subdural haemorrhage. After Ms Burrell called emergency se…

emergency medicineparamedicinedelaysystemalcohol
VIChospital2025-02-05

Finding into death of Daniel Francis McNeill

39y · Male·Complications following extradural haemorrhage (operated) sustained in an electr…

A 39-year-old man died from complications of extradural haemorrhage sustained in an e-scooter fall. He was riding a high-powered e-scooter (capable of 84 km/h, exceeding legal limits) while under the influence of methyla…

emergency medicineneurosurgerymethamphetamine
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