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VIChospital2025-10-28

Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …

Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarce…

infectious diseasesvascular surgerydiagnosticsystemantibiotics
VIChome2025-10-28

Finding into death of HCG

39y · Female·Unascertained

A 39-year-old woman experiencing intimate partner violence was assaulted by her partner on 31 January 2021 and died approximately 5 hours later. The assault caused significant blood loss; however, the medical cause of de…

forensic medicinepaediatricssystemcommunicationmethamphetamine
VIChospital2025-10-28

Finding into death of Jean Elizabeth Crocker

90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …

A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …

emergency medicinegeneral medicinemedicationdiagnosticwarfarin
VIC2025-10-27

Finding into death of Andrew Ewen Mallett

41y · Male·Undetermined, likely drowned

Andrew Mallett, a 41-year-old strong swimmer with fitness background, disappeared and is presumed drowned at Artillery Rock near Lorne on 28 November 2024. He entered the water to spearfish despite hazardous conditions i…

escitalopram
TAS2025-10-27

Coroner's Finding: Curtis, John Anthony

36y · Male·Traumatic brain injury, spinal cord infarction at level T6-conus and recurrent p…

36-year-old male died from catastrophic injuries sustained in a motorcycle crash. While excessive speed (120 km/h in a 70 km/h zone) was the predominant cause, the coroner noted the other driver failed to give way as leg…

WAcommunity2025-10-24

Inquest into the Suspected Death of Guido MICHEL

54y · Male·unascertained cause

Guido Michel, a 54-year-old electrician with longstanding mental health issues including depression, ADHD, and previous suicide attempts, disappeared in late January 2022 after entering State Forest near Flint, WA with c…

psychiatrygeneral practicesystemcommunicationdextroamphetamine
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
NTPodcast2025-10-24

Inquest into the death of Ebony Thompson

1y · Female·hypoxic brain injury caused by pressure to the neck from entrapment on a loop-to…

Ebony Thompson, aged 22 months, died from hypoxic brain injury caused by neck entrapment in a loop-topped chickencoop gate at a childcare centre. She became trapped while standing on a tricycle attempting to view chicken…

paediatricsemergency medicinesystemcommunication
QLDhospital2025-10-23

Inquest into the death of Shirley Elizabeth Haggett

78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…

78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…

anaesthesiaplastic and reconstructive surgerysystemdiagnosticmidazolam
NSW2025-10-22

Inquest into the Death of Frank Dwayne COLEMAN

43y · Male·methadone toxicity

Frank Coleman, a 43-year-old First Nations man, died of methadone toxicity after being supplied diverted methadone by another inmate while imprisoned at Long Bay Correctional Complex. Mr Coleman had repeatedly requested …

addiction medicinepsychiatrydiagnosticsystemmethadone
NSWmental health2025-10-20

Inquest into the Death of JSZ

66y · Male·Multiple blunt force injuries

JSZ, a 66-year-old forensic patient with chronic paranoid schizophrenia, died by suicide while on unsupervised day leave from Cumberland Hospital's Bunya Unit on 20 September 2023. He jumped from a cliff at Queen Elizabe…

psychiatryproceduralcommunicationzyprexa relprevv
SAcommunity2025-10-20

Coroner's Finding: Kennedy, John Douglas

65y · Male·Ischaemic heart disease on a background of hypertension

John Kennedy, 65, died from ischaemic heart disease with hypertension on 16 April 2020 after a 24-minute delay in ambulance dispatch. He called triple zero at 00:19 with severe chest pain and difficulty breathing (Priori…

emergency medicinecardiologycommunicationsystematenolol
VIChospital2025-10-17

Finding into death of Rachel Frances Piskun

42y · Female·Pneumonia, underlying severe cerebral palsy

Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…

emergency medicinegeneral medicinediagnosticmedicationmorphine
VIC2025-10-17

Finding into death of John Frank Stubbs

30y · Male·Multiple injuries sustained in a train impact (truck driver)

John Frank Stubbs, a 30-year-old truck driver, died when his low-loader truck became stuck on a railway level crossing with a 7.5% gradient and was struck by a train traveling at 32 km/h. The truck's low-slung trailer bo…

systemparacetamol
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
QLDhome2025-10-17

Inquest into the death of Alexandria Catherine Forrester

39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…

A 39-year-old woman with opioid dependency died from cardiac arrest caused by methadone toxicity. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatmen…

addiction medicinegeneral practicediagnosticmedicationmethadone
VIChospital2025-10-15

Finding into death of Gary William Bruce

71y · Male·Complications following a right hepatic artery injury following an open cholecys…

A 71-year-old man with myelofibrosis and prior abdominal surgery died from complications of a right hepatic artery injury during open cholecystectomy for acute cholecystitis. The operative decision was reasonable and the…

general surgeryanaesthesiacommunicationsystem
QLD2025-10-15

Inquest into the passing of ATJ

43y · Male·Hanging

A 43-year-old First Nations man died by hanging while remanded in custody for domestic violence offences. Initial risk assessments on admission were adequate—a psychologist appropriately assessed him as not requiring enh…

psychiatrypsychologycommunicationsystemamitriptyline
QLDhome2025-10-15

Inquest into the death of Tristian Jaemes Frahm

11y · Male·Brown snake envenomation

An 11-year-old boy died from brown snake envenomation after falling from a ride-on mower at a rural property. He exhibited early collapse symptoms (dizziness, vomiting, slurred speech) consistent with snake venom-induced…

emergency medicinetoxicologydiagnosticdelay
TASaged care2025-10-14

Coroner's Finding: de-identified XT

86y · Female·Hypostatic pneumonia due to the consequences of a right pubic rami fracture and …

An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…

geriatric medicineemergency medicinediagnosticcommunication
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