Coronial
VIChome2016

Finding into death of Alexander James McCulloch

35y · Male·Complications of morbid obesity in a man with cardiomegaly and schizophrenia

Alexander McCulloch, a 35-year-old man with schizophrenia, morbid obesity (BMI 45), and cardiomegaly, was found dead in bed. Autopsy attributed death to complications of morbid obesity with cardiomegaly and schizophrenia…

psychiatrygeneral practicecommunicationsystemfluphenthixol decanoate
QLD2013-03-28

Ware, Benjamin Richard

45y · Male·subdural haemorrhage sustained in a fall

Benjamin Ware, an intoxicated 45-year-old man, was taken by police to a diversionary centre in Cairns. He vomited several times during the evening and was monitored regularly by staff. The next morning, other clients wok…

diagnosticsystemalcohol
VIChospital2025-09-30

Finding into death of Robert Thoai Dao

73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…

A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…

paramedicineemergency medicinediagnosticprocedural
VIChospital2014-09-30

Finding into death of Iman Kassis

46y · Female·hemopericardium secondary to dissection of the thoracic aorta

Iman Kassis, a 46-year-old woman with Ehlers-Danlos Syndrome Type 4 and known severe aortic regurgitation with dilated ascending aorta, presented to the ED on 8 October 2008 with sudden-onset severe throat pain, bradycar…

emergency medicinecardiologydiagnosticdocumentationflecainide
ACThome2012-09-24

Inquest Into The Death Of Stephen Moon

21y · Male·cardiac arrest caused by acute bilateral pneumonia

Stephen Moon, a 21-year-old with autism and intellectual disability, died following wisdom tooth extraction complicated by ventilator-acquired pneumonia. Although discharged early from ICU after 3 days, he developed bila…

anaesthesiaintensive caredelaycommunicationpropofol
WAmental health2018-07-16

Inquest into the Death of Stanley KING

45y · Male·Cardiorespiratory arrest due to coronary artery disease, severe psychosis requir…

Stanley King, a 45-year-old man with severe psychosis, coronary artery disease, and obesity, died from cardiorespiratory arrest triggered by antipsychotic-induced laryngeal dystonia. Admitted involuntarily for acute psyc…

psychiatryemergency medicinediagnosticmedicationzuclopenthixol
WAmental health

Inquest into the Death of David GRIEVE

45y · Male·Coronary Atherosclerosis

David Grieve, a 45-year-old man with chronic schizophrenia and multiple cardiac risk factors (hypertension, diabetes, obesity, smoking), died of coronary atherosclerosis while an involuntary psychiatric patient at Grayla…

psychiatrycardiologysystemcommunicationhaloperidol
NSWmental health2025-03-28

Inquest into the death of NL

62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval

NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with …

psychiatryendocrinologydiagnosticcommunicationthyroxine
SAhospital2025-06-12

Coroner's Finding: Salter, Kathleen Ethel

76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy

A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the com…

general surgeryanaesthesiadiagnosticproceduralapixaban
SAhospital2026-02-26

Coroner's Finding: Taylor, Warren Richard

79y · Male·Urinary tract infection with E coli bacteraemia on a background of ischaemic hyp…

A 79-year-old man with multiple comorbidities attended Whyalla Hospital ED following a fall. Paramedics documented concerning vital signs (tachypnoea, tachycardia, low oxygen saturation, fever) and a history suggestive o…

emergency medicinegeneral practicediagnosticcommunicationtrimethoprim
NSWhospital2019-09-04

Inquest into the death of Ivan METCALFE

82y · Male·Complications associated with advanced chronic lung disease

Ivan Metcalfe, aged 82, died of complications from advanced chronic lung disease while in prison custody. He had multiple comorbidities including diabetes, ischaemic cardiovascular disease, and atrial fibrillation. He wa…

respiratory medicinecardiologycommunicationsystemantibiotics
QLDhome2019-04-17

Davis, John

50y · Male·Hypoxic-ischaemic encephalopathy secondary to choking on food bolus

A 50-year-old man with acquired brain injury and intellectual disability died from hypoxic-ischaemic encephalopathy following aspiration of a food bolus during lunch at his disability care residence. The carer appropriat…

emergency medicineparamedicinediagnosticcommunicationmidazolam
QLD2009-08-21

Oram, Ronald Thomas

49y · Male·Coronary artery occlusion due to, or as a consequence of, coronary artery athero…

Ronald Thomas Oram, a 49-year-old Aboriginal man, died in custody from natural causes—severe coronary artery atheroma with coronary artery occlusion. He presented to the prison nurse on 5 January 2008 with chest pain, wh…

emergency medicinecardiologydiagnosticsystemparacetamol
QLD2018-08-10

Harmer, Jay Maree

38y · Female·Complications of decompensated liver failure due to cirrhosis secondary to Hepat…

Jay Maree Harmer, 38, died in custody from decompensated liver failure secondary to Hepatitis C cirrhosis. She had advanced hepatic encephalopathy, opioid dependence, and obesity. Despite specialist recommendations to re…

gastroenterologypalliative carecommunicationdelaybuprenorphine
NSWhospital2018-04-26

Inquest into the death of Margaret Ann Pegum

67y · Female·Sepsis as a result of gastric perforation

Margaret Pegum, aged 67, died from sepsis following gastric perforation after an intragastric balloon (IGB) procedure for weight loss. She had undergone fundoplication for hiatus hernia in 2012. Despite prior gastric sur…

gastroenterologybariatric surgerydiagnosticcommunication
VICaged care2021-04-23

Finding into death of Josephine Helen Clarke

69y · Female·Complications of a subdural haemorrhage (palliated) sustained in a fall

Josephine Helen Clarke, age 69, died from complications of a subdural haemorrhage sustained in a fall at Kingston Centre rehabilitation facility on 11 September 2018. Mrs Clarke had been recovering from a subarachnoid ha…

geriatric medicineneurosurgerysystemcommunication
WAcommunity2026-02-02

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, 24, with Sotos syndrome, dilated cardiomyopathy, asthma, and WHO class III obesity (BMI 40.6) died from cardiac arrest on 16 June 2023 after being restrained in prone position by PTA transit o…

communicationproceduralalcohol
QLDhospital2024-07-30

PATELESIO, Etevise

29y · Female·Hypoxic-ischaemic encephalopathy due to cardiac arrest of undetermined cause

A 29-year-old woman with multiple comorbidities (Turner syndrome, type 1 diabetes, end-stage renal disease) presented to the ED in acute behavioural disturbance, requiring physical and chemical restraint. She received 5m…

emergency medicineintensive caremonitoringsystemdroperidol
QLDhospital2019-07-24

Mr P - Non-inquest findings

47y · Male·Pulmonary thrombo-embolism secondary to deep vein thrombosis in setting of morbi…

A 47-year-old man with morbid obesity presented with respiratory failure, productive cough, and calf swelling. His GP appropriately suspected both pneumonia and pulmonary embolism (PE), requesting urgent CTPA. At Townsvi…

intensive careemergency medicinediagnosticcommunicationheparin
VIChospital2022-05-09

Finding into death of Robert Albert Burns

75y · Male·Multiorgan dysfunction syndrome complicating anastomotic leak following hemicole…

A 75-year-old man died from multiorgan dysfunction following an anastomotic leak after hemicolectomy for caecal adenocarcinoma. Initial post-operative recovery appeared normal, but he deteriorated from day 3 onwards. The…

colorectal surgeryintensive carediagnosticdelay

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