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VICaged care2026-04-28

Finding into death of Graham Peter Moore

61y · Male·Pneumonia complicating Trisomy 21

Graham Peter Moore, a 61-year-old man with Down syndrome, epilepsy, and early-onset dementia living in residential care, died of pneumonia on 8 December 2025. He developed community-acquired pneumonia in late November, w…

respiratory medicineinfectious diseases
VICcommunity2026-04-13

Finding into death of David Evan Wild

61y · Male·Natural causes unascertained

David Evan Wild, 61 years old, died of natural causes of unascertained origin while residing in specialist disability accommodation. He had frontal temporal dementia diagnosed in 2020 and required 24/7 care. He experienc…

geriatric medicineneurologyfluoxetine
WAhospital2026-04-01

Inquest into the Death of David John HATCHER

60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…

A 60-year-old man remanded in custody died from pulmonary tuberculosis complicated by severe COPD. Key clinical issues included: delayed diagnosis (TB not suspected at intake despite respiratory symptoms), patient's refu…

respiratory medicineinfectious diseasessystemdelaytb treatment
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
NT2026-03-19

Inquest into the death of Bradley Murdoch

66y · Male·metastatic adenocarcinoma (palliated) from an unidentified primary tumour

Bradley John Murdoch, a 66-year-old prisoner serving a life sentence for murder, died in the palliative care unit of Alice Springs Hospital from metastatic adenocarcinoma on 15 July 2025. He had presented to the correcti…

oncologypalliative carecarboplatin
VIChospital2026-03-19

Finding into death of Richard Watson

62y · Male·Aspiration pneumonia complicating epilepsy in the setting of Down syndrome

Richard Watson, a 62-year-old man with Down syndrome, epilepsy, dementia and C1 partial quadriplegia, died from aspiration pneumonia at Austin Hospital. He had recurrent admissions over six months for pneumonia, asthma a…

emergency medicinerespiratory medicine
VIC2026-03-19

Finding into death of Judith Gail Longhurst

74y · Female·Chronic obstructive pulmonary disease

Judith Gail Longhurst, a 74-year-old woman with cerebral palsy, dysphagia, and multiple comorbidities, died of chronic obstructive pulmonary disease (COPD) on 23 October 2024 at her Specialist Disability Accommodation re…

respiratory medicinegeneral practicesertraline
VICaged care2026-03-16

Finding into death of Michelle Anne Leiper

59y · Female·Aspiration pneumonia and urosepsis complicating Alzheimer's dementia in setting …

Michelle Anne Leiper, aged 59 with Down syndrome and Alzheimer's dementia, died from aspiration pneumonia and urosepsis. She had significant dysphagia and was largely bedbound in her final years. After a February 2025 ho…

geriatric medicinepalliative care
SAhospital2026-03-13

Coroner's Finding: Schlaefer, Norbert

69y · Male·disseminated urothelial carcinoma of the bladder (palliated), bilateral lung ade…

A 69-year-old man died in prison custody from disseminated urothelial carcinoma of the bladder, bilateral lung adenocarcinoma, and severe emphysema. He had a significant smoking history and prior asbestos exposure. His l…

oncologyrespiratory medicine
NSWhospital2026-02-26

Inquest into the death of Jeremy Webb

16y · Male·Anaphylaxis due to mammalian meat allergy after tick bite, causing an acute exac…

Jeremy Webb, 16, died from anaphylaxis due to mammalian meat allergy (tick-induced) which triggered status asthmaticus. He had experienced red meat reactions since age 10 and a severe respiratory event in April 2021 that…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline
VIChospital2026-02-25

Finding into death of Louise Elizabeth Hayes

49y · Female·Aspiration pneumonia in the setting of cerebral palsy and epilepsy

Louise Hayes, a 49-year-old woman with cerebral palsy, epilepsy, and dysphagia, died from aspiration pneumonia at Kilmore & District Hospital. She had experienced deteriorating health in 2020 with increased seizures and …

respiratory medicinepalliative care
WAhospital2026-02-23

Inquest into the Death of Child MML

11y · Male·bronchopneumonia and small bowel necrosis with perforation, in a boy with multic…

An 11-year-old Aboriginal boy died from bronchopneumonia and small bowel necrosis with perforation, following severe neurological impairment from an inflicted brain injury sustained at 8 months old. His parents delayed s…

neurologypaediatricscommunicationsystem
VIChospital2026-02-20

Finding into death of James Harilaos Tsindos

17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis

James Tsindos, a 17-year-old with known nut allergy and mild asthma, experienced anaphylaxis after inadvertently ingesting cashews in a vegan restaurant meal on 27 May 2021. Ambulance paramedics administered two doses of…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline (epinephrine) intramuscular
NSWmental health2026-02-19

Inquest into the death of Jacob McDonald

51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…

Jacob MacDonald, 51, died at the Forensic Hospital from combined effects of dilated cardiomyopathy with myocardial fibrosis and toxic levels of clozapine and aripiprazole. He was an involuntary forensic psychiatric patie…

psychiatrycardiologycommunicationsystemclozapine
QLDcommunity2026-02-13

Inquest into the passing of Steven Lee Nixon-McKellar

27y · Male·Sudden cardiac arrest in the context of physical and psychological exertion duri…

Steven Nixon-McKellar, a 27-year-old First Nations man, died following a physical altercation with Queensland Police officers attempting to arrest him on 7 October 2021. He suffered cardiac arrest during restraint, with …

emergency medicineforensic medicinemethamphetamine
VIChome2026-02-03

Finding into death of Jeffrey Thomas Wilson

76y · Male·Effects of fire due to home oxygen ignition in the setting of smoking; lung canc…

A 76-year-old man with lung cancer and mesothelioma died from thermal injuries sustained when his home oxygen ignited while smoking. He had been discharged on self-funded home oxygen despite a recent smoking history, aft…

respiratory medicinepalliative caresystemdelay
WA2026-02-02

Inquest into the Death of Joshua Fredrik VAN MALSSEN

24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…

Joshua Fredrik Van Malssen, a 24-year-old man with Sotos syndrome, complex cardiac disease, asthma, and obesity, died from cardiac arrest after being restrained in the prone position during a lawful arrest by Public Tran…

cardiologyrespiratory medicinecommunicationsystemloratadine
VIChospital2026-01-13

Finding into death of Sushant Padhye

56y · Male·Recurrent aspiration pneumonia in a man with congenital disability and cognitive…

A 56-year-old man with congenital microcephaly, intellectual disability, dysphagia and recurrent aspiration pneumonia died from aspiration pneumonia whilst receiving palliative care in hospital. He had multiple episodes …

emergency medicinepalliative carecarbamazepine
NSWhospital2026-01-13

Inquest into the death of Paul Harris

43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…

Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …

general practiceemergency medicinediagnosticcommunicationceftriaxone
VIChospital2026-01-12

Finding into death of Lydia Christopherson

39y · Female·Undifferentiated large right pleural effusion

Lydia Christopherson, a 39-year-old woman with cerebral palsy, intellectual disability, and epilepsy living in supported accommodation, died from a large right pleural effusion complicated by chest infection. She present…

respiratory medicineemergency medicine
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