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VIChomeNew2026-06-10

Finding into death of Laura Claire Brady

41y · Female·Aspiration pneumonia complicating an ischaemic stroke in a woman with epilepsy, …

Laura Claire Brady, aged 41, was a Specialist Disability Accommodation (SDA) resident with cerebral palsy, severe epilepsy, and intellectual disability. In December 2024, she deteriorated while in SDA care, presenting wi…

neurologyemergency medicine
VIChomeNew2026-06-10

Finding into death of Patricia Elizabeth Davidson

53y · Female·Pneumonia

Patricia Elizabeth Davidson, aged 53, died of pneumonia on 1 October 2024 at Sunshine Hospital. She was a resident in Specialist Disability Accommodation with Parkinson's disease, intellectual disability, autism, epileps…

emergency medicinegeneral medicine
NSWhospitalNew2026-06-01

Inquest into the death of Michael Anthony Guider

73y · Male·Thromboembolism on a background of a spindle cell tumour

Michael Anthony Guider, aged 73, was an inmate in NSW correctional custody when he developed progressive shortness of breath and lower limb swelling. He presented to Prince of Wales Hospital on 6 September 2024 and was f…

cardiologycorrectional health
WAcommunityNew2026-05-27

Inquest into the Death of David GRAY

58y · Male·Gunshot injury to the abdomen

David Gray, 58, deliberately induced police to shoot him as a means of suicide following undisclosed mental health deterioration. On 22 September 2023, he called police anonymously reporting an armed person, then present…

emergency medicineforensic medicine
QLD2026-05-26

Inquest into the death of Desmond George Buckby

74y · Male·Left cerebral ischaemic stroke caused by cerebral arterial cardioembolism

Desmond George Buckby, a 74-year-old prisoner detained under the Dangerous Prisoners (Sexual Offenders) Act, suffered a massive left cerebral ischaemic stroke caused by cardioembolism while in Wolston Correctional Centre…

emergency medicineneurologyalteplase
VIChome2026-05-25

Finding into death of Robyn Julia Richards

69y · Female·Hydrocephalus and subarachnoid haemorrhage in the setting of a fall in a woman w…

A 69-year-old woman with cerebral palsy, intellectual disability, and B cell acute lymphoblastic leukaemia, residing in Specialist Disability Accommodation funded through the National Disability Insurance Scheme, sustain…

general practiceparamedicine
VIChospital2026-05-22

Finding into death of Stratos Ioannidis

45y · Male·focal coronary artery disease and cardiomegaly

Stratos Ioannidis, age 45, died at Maroondah Hospital on 28 March 2025 from focal coronary artery disease and cardiomegaly during an involuntary psychiatric admission. He presented with acute psychosis from bipolar disor…

psychiatryemergency medicinecommunicationsystemolanzapine
NSWhospital2026-05-14

Inquest into the death of Meirion Thomas Morris

67y · Male·Complications of chronic obstructive pulmonary disease

A 67-year-old man with end-stage chronic obstructive pulmonary disease was serving a lengthy prison sentence in Corrective Services NSW custody at Long Bay Hospital's Aged Care and Rehabilitation Unit. In early October 2…

correctional healthpalliative caremorphine
ACThospital2026-05-12

Inquest into the death of Mr Deleman

69y · Male·peritonitis due to perforated bowel

Mr Deleman was a 69-year-old man with untreated schizophrenia, advanced liver cirrhosis, and hepatitis C, presenting to hospital on 1 April 2024 with abdominal swelling. He was admitted to The Canberra Hospital and place…

emergency medicinegastroenterologypaliperidone
VICcommunity2026-05-07

Finding into death of Elizabeth Susan Edwina Ferris

44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…

Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…

psychiatryintensive carediagnosticcommunicationheroin
VICaged care2026-05-06

Finding into death of Cornelia Groot

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…

geriatric medicineemergency medicinediagnosticcommunicationoxycodone
NSWchildcare2026-05-06

Inquest into the death of Arianna Maragol

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…

paediatricsemergency medicinesystemcommunicationibuprofen
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
VICaged care2026-04-30

Finding into death of Sandra Susan Black

54y · Female·Aspiration pneumonia secondary to Alzheimer's dementia complicating Down's Syndr…

Sandra Black, aged 54, died from aspiration pneumonia secondary to Alzheimer's dementia complicating Down Syndrome. She lived in specialist disability accommodation and had a long history of recurrent aspiration pneumoni…

general practiceemergency medicineantibiotics
TAScommunityNew2026-04-28

Coroner's Finding: Thompson, Damian Brian

71y · Male·Multiple injuries sustained in motorcycle crash

Damian Brian Thompson, aged 71, crashed his motorcycle on a rural road in Tasmania during torrential rain, sustaining severe injuries to his left leg and left hand. He was transported to Launceston General Hospital where…

emergency medicineintensive care
VICmental health2026-04-27

Finding into death of GM

Female·Fulminant hepatic failure due to paracetamol toxicity

A 19-year-old female with anorexia nervosa, borderline personality disorder, and chronic suicidality was admitted to St Vincent’s psychiatric inpatient unit on 28 July 2023. She reported ongoing suicidal thoughts but eng…

psychiatryintensive careparacetamol
QLD2026-04-24

Findings of the Inquest into the death of Benjamin Freear

40y · Male·Gunshot wound to neck

Benjamin Freear, aged 40, died from a gunshot wound to the neck sustained during a police siege on 8 December 2019 in rural Queensland. He had been diagnosed with ADHD in April 2018 and prescribed dexamphetamine by psych…

psychiatrygeneral practicesystemdextroamphetamine
SAhospital2026-04-23

Coroner's Finding: Wilson, Charles Thomas

85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …

An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …

cardiologygeriatric medicinemedicationcommunicationmetoprolol
VIC2026-04-22

Finding into death of Natasha Stojkoski

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…

psychiatryoccupational and environmental healthsystemcommunicationescitalopram
NSWhome2026-04-21

Inquest into the death of Michael

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 …

emergency medicineparamedicinesystemcommunicationvenlafaxine

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