Coronial
WAhospital2026-04-01

Inquest into the Death of David John HATCHER

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

David John Hatcher, aged 60, was a remand prisoner at Hakea who died at Fiona Stanley Hospital on 27 September 2024 from pulmonary tuberculosis superimposed on severe chronic obstructive pulmonary disease. He was hospita…

respiratory medicineinfectious diseasesproceduralsystem
WAhospital2022-06-08

Inquest into the Death of Salvatore Giovanni OTRANTO

68y · Male·Complications following myocardial infarction and its treatment in a man with mu…

…nto, a 68-year-old prisoner with multiple severe comorbidities including ischaemic heart disease, diabetes, COPD, and chronic kidney disease, died from complications of myocardial infarction and its treatment. Admitted t…

cardiologyintensive careproceduralenoxaparin
QLD2010-05-19

Jeffrey, Lawrence Edward

63y · Male·Metastatic carcinoma of the lung

… carcinoma on 11 May 2008. He presented with symptoms consistent with his known chronic conditions (asthma, COPD, silicosis from occupational exposure) but these masked underlying advanced lung cancer. The coroner identi…

general practicerespiratory medicinediagnosticdelayfurosemide
WAhospital2017-05-03

Inquest into the Death of Edith Catherine BEE

80y · Female·Gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm …

An 80-year-old woman with multiple comorbidities (COPD, renal impairment, cardiac disease) underwent complex endoluminal repair of a thoracoabdominal aortic aneur…

vascular surgerygeneral surgeryproceduralsystem
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
VIChospital2014-08-21

Finding into death of Neville Ross

65y · Male·Cardiac tamponade whilst undergoing CT-guided pericardiocentesis; perforation of…

A 65-year-old man with history of left pneumonectomy, COPD and cardiomyopathy died from cardiac tamponade during CT-guided pericardiocentesis. Key clinical issues: (1…

cardiologyradiologydiagnosticprocedural
QLD2022-11-15

Childs, Dennis William

64y · Male·Peritonitis, due to or as a consequence of a ruptured gallbladder, due to or as …

Dennis Childs, a 64-year-old Indigenous man serving a life sentence, died from peritonitis secondary to a ruptured gallbladder. On 8 December 2018, he presented with abdominal pain at the correctional centre but refused …

emergency medicinegeneral surgerydiagnosticdelaymorphine
QLD2021-09-20

Harris, John Edward

47y · Male·Hanging

John Harris, a 47-year-old life prisoner at Townsville Correctional Centre, died by hanging in his cell on 4 July 2019. He had an elevated baseline suicide risk due to a previous 2012 suicide attempt, yet was housed in a…

correctional healthpsychologyassessmentsystemcarbamazepine
NSWhospital2015-03-16

Inquest into the death of John Gibson

63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…

A 63-year-old man with COPD, liver cirrhosis and alcohol dependence underwent emergency hemicolectomy for caecal volvulus. Post-operati…

surgeryanaesthesiaproceduraldiagnosticdiazepam
WAhospital2024-08-28

Inquest into the Death of Matthew John PICKIN

56y · Male·Complications, including sepsis, of left leg infection (operated), in a man with…

Matthew John Pickin, a 56-year-old prisoner with metastatic lung adenocarcinoma, died from sepsis complicating a left leg infection. His lung cancer was appropriately investigated following haemoptysis in October 2021, w…

respiratory medicineoncologysystemdexamethasone
WA2024-07-10

Inquest into the Death of Kevin John KEATH

76y · Male·metastatic prostate cancer with terminal palliative care

Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including r…

oncologypalliative caresystemdelay
QLD2020-11-16

Haynes, Barry

58y · Male·Metastatic non-small cell lung carcinoma

Barry Haynes, a 58-year-old Aboriginal man, died of metastatic non-small cell lung carcinoma while on remand in custody. He had stage 4 lung cancer with brain metastases diagnosed in November 2016, shortly before his arr…

oncologypalliative caresystemdelay
WAhospital2022-06-23

Inquest into the Death of Lee MILCHERDY

75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…

Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the plann…

gastroenterologygeneral surgerycommunicationdiagnostic
NSWaged care2012-05-11

Inquest into the deaths of Shaneen BATTS, Ilona TAKACS, Dorothy HUDSON, Ian BIRKS, Donald MacKELLAR and Mohammed RAMZAN

Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …

…hrenia on multiple antipsychotic medications and severe, untreated physical comorbidities (cardiac disease, COPD, obesity). The coroner found preventable clinical failures: (1) antipsychotic polypharmacy without toxicity…

psychiatrygeneral practicediagnosticmedicationolanzapine
NThospital2026-01-09

Inquest into the death of C Guyula

49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …

A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incisi…

anaesthesiasurgeryproceduralmedicationfentanyl
WAhospital2013-09-24

Inquest into the Death of Whiteford, Carol Freda

68y · Female·Anaphylaxis in a woman with atherosclerotic cardiovascular disease and emphysema

A 68-year-old woman with severe COPD and undiagnosed atherosclerotic heart disease underwent cataract surgery at Northam Hospital. Post-operativ…

ophthalmologyanaesthesiadiagnosticmedicationdiamox
NSWhome2018-05-02

Inquest into the death of Peter Bernard Woodcroft

78y · Male·Heart failure or arrhythmia, secondary to ischaemic heart disease

Peter Woodcroft, 78, suffered a medical emergency (heart failure or arrhythmia secondary to ischaemic heart disease) at 4:32am and called Triple Zero but could not articulate what he needed. Police did not attend his Wat…

emergency medicinecardiologycommunicationsystemfurosemide
TAShome2026-01-22

Coroner's Finding: Kerrie Dawn Grant

72y · Female·acute on chronic renal failure due to sepsis and chronic left leg cellulitis

…n Grant, a 72-year-old woman with multiple comorbidities including pulmonary hypertension, cardiac failure, COPD, and myelofibrosis, had a well-documented history of recurrent falls with prolonged periods unable to self-…

general medicinecardiologydischargecommunication
WA2022-02-04

Inquest into the Death of Robert William ROMAN

55y · Male·Subdural haematoma in a man with diabetes mellitus and chronic kidney disease (r…

A 55-year-old Aboriginal man with end-stage renal disease, diabetes, ischaemic heart disease and COPD died from a spontaneous subdural haematoma while undergoing haemodialysis in prison custody. He presented w…

nephrologyemergency medicinesystemcommunicationaspirin
VIChospital2026-04-24

Finding into death of Mr JNY

Male·Pulmonary thromboembolism and bronchopneumonia secondary to deep vein thrombosis

JNY, a man with metastatic small cell carcinoma, COPD, and ischaemic heart disease, died from pulmonary thromboembolism and bronchopneumonia. He received palliat…

palliative caregeneral practicesystemdesvenlafaxine

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