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VICNew2026-08-27

Finding into death of Allan James Anton

64y · Male·Complications of Alzheimer's dementia

Allan Anton, aged 64, died on 24 September 2025 from complications of Alzheimer's dementia at his specialist disability accommodation in Tarneit. He was diagnosed with younger onset dementia in November 2021 following a …

general practiceoccupational therapy
SAaged careNew2026-08-21

Coroner's Finding: Clark, Wayne Malcolm

84y · Male·bronchopneumonia complicating C2 odontoid fracture (palliated) due to fall on a …

Wayne Malcolm Clark, aged 84, with advanced Alzheimer's and vascular dementia, fell in a secure residential aged care facility and sustained a C2 odontoid fracture. He died on 23 August 2023 from bronchopneumonia complic…

general practiceparamedicineparacetamol
VIChomeNew2026-08-20

Finding into death of Dorothy Boag

91y · Female·Aspiration pneumonia in a woman with multiple co-morbidities

91-year-old woman with disability living in specialist disability accommodation who died from aspiration pneumonia. She had documented moderate oropharyngeal dysphagia from prior stroke, managed with pureed diet and thic…

general practicegeriatric medicine
VIChomeNew2026-08-07

Finding into death of TPK

6y · Unknown·Complications of Pelizaeus-Merzbacher disease

TPK was a 6-year-old with Pelizaeus-Merzbacher disease (PMD), a progressive neurodegenerative leukodystrophy diagnosed at birth causing profound disability and seizures. Placed with foster parents Mr and Mrs JEP via Depa…

paediatricspalliative caremethadone
SAhome2026-07-07

Coroner's Finding: Morland-Shearer, Debra

64y · Female·choking on food on a background of Alzheimer's disease and antipsychotic therapy

Debra Jayne Morland-Shearer, aged 64, died on 11 January 2023 from choking on food while living in supported community care under a Guardianship Order. She had Alzheimer's disease, mild dysphagia diagnosed in November 20…

speech pathologypsychiatryquetiapine
TASaged care2026-05-19

Coroner's Finding: de-identified BE

85y · Male·systemic sepsis due to infected right perineal ulcer and associated perianal abs…

An 85-year-old man with dementia and multiple comorbidities died of sepsis caused by an infected sacral pressure ulcer that developed and deteriorated while resident at an aged care facility. Initially assessed as stage …

geriatric medicinegeneral practicedelaymedication
VICaged care2026-04-28

Finding into death of Saba Pietropaolo

90y · Female·Choking

A 90-year-old woman with dysphagia died from choking after consuming thin fluid (coffee) against medical recommendation. She had been reviewed by a speech pathologist on 15 November 2024 who recommended thick fluids only…

geriatric medicinespeech pathologysystem
VIC2026-03-03

Finding into death of Susan June Mahoney

74y · Female·Acute renal failure complicating decreased oral intake in the setting of Angelma…

Susan June Mahoney, a 74-year-old woman with Angelman syndrome, died from acute renal failure secondary to progressively declining oral intake. From April 2025, staff observed reduced food and fluid intake with swallowin…

general practiceemergency medicine
NSWaged care2026-02-27

Inquest into the deaths of Dimosthenis Gesios and Maureen McGreevy

Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…

Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed bread dipped in Milo by an inexperienced AIN without adequate supervisio…

speech pathologygeneral practicesystemcommunication
WAhome2026-02-23

Inquest into the Death of Child MML

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

Child MML was an Aboriginal boy born in April 2010 who suffered catastrophic abusive head trauma at eight months old in December 2010, causing severe lifelong neurological impairment including cerebral palsy, uncontrolle…

neurologypaediatricscommunicationsystem
QLDhome2026-02-03

Inquest into the death of Bridie Gilligan

42y · Female·Hypoxic brain injury due to choking on food, with Cornelia de Lange Syndrome con…

Bridie Gilligan, 42, with Cornelia de Lange Syndrome, intellectual disability, and dysphagia, choked on a Yumbo burger in her Supported Independent Living accommodation on 29 April 2021, suffering fatal hypoxic brain inj…

speech pathologydieteticssystemcommunication
VIChospital2025-12-11

Finding into death of Barbara Grace Bright

73y · Female·Pneumonia (palliated)

Barbara Grace Bright, 73, died of pneumonia at Frankston Hospital. She was a long-term resident of specialist disability accommodation with cerebral palsy, dysphagia, epilepsy, and intellectual disability. From July 2024…

geriatric medicinespeech pathology
VIC2025-11-10

Finding into death of Andrew Phillip John Kursinskis

57y · Male·Complications following food aspiration in a man with multiple co-morbidities

Andrew Kursinskis, a 57-year-old man with intellectual disability, dysphagia, autism, epilepsy and pica, died from complications following aspiration of chicken schnitzel while living in supported disability accommodatio…

speech pathologyemergency medicinesystemcommunicationlevetiracetam
VICaged care2025-10-10

Finding into death of Christopher Kuric

52y · Male·Aspiration pneumonia in a man with end stage Huntington's disease

Christopher Kuric, a 52-year-old man with end-stage Huntington's disease residing in specialist residential care, died of aspiration pneumonia. He had documented swallowing difficulties managed by speech pathology and di…

neurologypalliative carepossibly_preventabledelay
VIC2025-09-10

Finding into death of Tracie Lyndal Markwick

54y · Female·choking on a food bolus in a woman with an intellectual disability and other med…

Tracie Lyndal Markwick, a 54-year-old woman with intellectual disability and dysphagia, died from choking on food at her day placement centre. She had a documented mealtime management plan indicating mild-to-moderate cho…

speech pathologyemergency medicineamisulpride
VIChospital2025-08-22

Finding into death of Tracey Ellen Maree Wood

60y · Female·Pneumonia with large pleural effusion

Ms Wood, a 60-year-old woman with Down syndrome, Alzheimer's disease and epilepsy residing in specialist disability accommodation, developed pneumonia with large pleural effusion and died in hospital. A speech pathologis…

general medicinespeech pathology
VICcommunity2025-07-17

Finding into death of John Michael Jurdeczka

62y · Male·Hypoxic ischaemic encephalopathy complicating cardiac arrest in setting of acute…

John Michael Jurdeczka, a 62-year-old man with autism, intellectual disability, and dysphagia, died from hypoxic ischaemic encephalopathy following cardiac arrest caused by acute upper airway obstruction from a food bolu…

speech pathologygeneral practicecommunicationsystemmorphine
QLDhome2025-07-15

Inquest into the death of Daniel Thomas Wright

<1y · Male·prematurity-associated lung and bowel disease

Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associate…

neonatologypaediatricsdiagnosticcommunication
VIChospital2025-06-30

Finding into death of Ross Robert Richards

75y · Male·aspiration pneumonia in the setting of Parkinson's disease and other medical com…

Ross Richards, a 75-year-old man with Parkinson's disease and dysphagia, died from aspiration pneumonia at Box Hill Hospital. He resided in specialist disability accommodation and had been assessed as high-risk for aspir…

geriatric medicinerespiratory medicine
VIChospital2025-06-25

Finding into death of Melanie Louise Gregory

39y · Female·aspiration pneumonia in the setting of general anaesthesia and colonoscopy for i…

A 39-year-old woman with cerebral palsy, dysphagia, and sleep apnoea died from aspiration pneumonia following a colonoscopy performed under sedation for investigation of rectal bleeding. She had known increased aspiratio…

gastroenterologyanaesthesia

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