Coronial
WAhospital- 11 April 2014

Inquest into the Death of Kevin Maxwell COLLINS

50y · Male·bronchitis (pandemic influenza A/H1N1 2009) in a man with chronic obstructive pu…

Kevin Maxwell Collins, a 50-year-old man with chronic schizophrenia, chronic obstructive pulmonary disease, and morbid obesity, died from bronchitis due to pandemic influenza A/H1N1 2009 while an involuntary patient at G…

psychiatryrespiratory medicineclozapine
TAShome2018-12-17

Coroner's Finding: Pitchford, Rhiannon Pearl Vanessa

0y · Female·Sudden infant death whilst bed-sharing with risk factors including unsafe sleepi…

…e autopsy revealed no obvious cause, but documented face-down positioning, respiratory infection, passive smoking exposure, and unsafe sleep environment. Critical failures by Child Safety Services included: premature cl…

paediatricsforensic medicinesystemdelaymorphine
WA

Inquest into the Death of Dragan JACOVIC

63y · Male·ischaemic heart disease

Dragan Jacovic, a 63-year-old life prisoner with extensive comorbidities including severe ischaemic heart disease, type 2 diabetes, chronic kidney disease, and chronic paranoid schizophrenia, was admitted to hospital on …

cardiologypsychiatryolanzapine
WAhospital2025-12-05

Inquest into the Death of Leslie Charles LINTON

64y · Male·acute myocardial infarction in association with coronary artery atherosclerosis

Leslie Charles Linton, a 64-year-old man with severe triple-vessel coronary artery disease, presented to Royal Perth Hospital on 15 December 2023 with an infected foot wound and acute psychosis. Initial troponin elevatio…

cardiologypsychiatryrisperidone
VIChome2016-07-05

Finding into death of Medzit Jakupi

66y · Male·Unascertained (natural causes)

Mr Jakupi, a 67-year-old man with hypertension, hypercholesterolaemia, type 2 diabetes and smoking history, called emergency services at 5:12am reporting shortness of breath. Ambulance paramedics were dis…

emergency medicineparamedicinesystemcommunicationcodeine
SAhospital2015-08-27

Coroner's Finding: O'LEARY Judith Beverley

75y · Female·exacerbation of end-stage chronic obstructive pulmonary disease

Judith Beverley O'Leary, 75-year-old woman with end-stage COPD, dementia, depression and multiple comorbidities, died from exacerbation of COPD with secondary respiratory tract infection. She was placed under guardianshi…

respiratory medicineemergency medicinequetiapine
SAhome2014-01-31

Coroner's Finding: ROWAN Marjorie June

52y · Female·ischaemic and hypertensive heart disease

A 52-year-old woman with depression, diabetes, and hypertension died at home from ischaemic and hypertensive heart disease. She was prescribed dothiepin 225mg daily for depression management. Following gallbladder surger…

psychiatrygeneral practicedosulepin
WAhospital2019-08-30

Inquest into the Death of James Ronald CHI

69y · Male·Chronic obstructive pulmonary disease and coronary artery atherosclerosis

James Ronald Chi, aged 69, died from chronic obstructive pulmonary disease and coronary artery atherosclerosis at Broome Hospital. He was an involuntary mental health patient with treatment-resistant bipolar disorder and…

psychiatryemergency medicineclozapine
WAhospital2022-11-03

Inquest into the Death of Jeffery William ROONEY

41y · Male·subarachnoid haemorrhage due to rupture of a berry aneurysm of the right interna…

A 41-year-old male prisoner died from subarachnoid haemorrhage caused by rupture of an undiagnosed berry aneurysm while incarcerated. He had a complex medical history including migraines, head injuries, hypertension, and…

neurosurgeryemergency medicineamitriptyline
VIChome2024-04-23

Finding into death of Robert Norman Spencer

59y · Male·ischaemic heart disease in the setting of chronic ethanol use

Robert Spencer, 59, called 000 at 4:27 am reporting weakness and inability to mobilise following a fall. He was triaged as Code 3 (non-urgent) and underwent secondary triage call-back attempts without success. An ambulan…

emergency medicineparamedicinesystemdelay
WAhospital2020-12-02

Inquest into the Death of Simon John SHARPE

Male·non-specific interstitial pneumonia

Simon John Sharpe, a sentenced prisoner with incurable non-specific interstitial pneumonia, died on 30 June 2017 at Fiona Stanley Hospital from progression of his lung disease. Throughout his 17-month imprisonment, Sharp…

respiratory medicinetransplant medicine
NSWcommunity2026-01-20

Inquest into the disappearance and suspected death of AL

35y · Male·The available evidence does not allow for any finding to be made as to the cause…

…ecember 2021 and set his house on fire in August 2022. On the evening of his death, he was observed chain smoking and pacing, told his uncle he was not coming home, and was last seen walking toward the Macquarie Lightho…

psychiatrypsychology
SAhospital2005-04-07

Coroner's Finding: HARRIS Margret Lillian

48y · Female·Chronic Obstructive Airway Disease

Margret Lillian Harris, aged 48, died of chronic obstructive airway disease while detained under the Mental Health Act at Royal Adelaide Hospital. She had longstanding COAD, right heart failure, chronic hypoxia and cyano…

psychiatryrespiratory medicinediuretics
NSWhospital2023-02-10

Inquest into the death of Anzac Sullivan

38y · Male·Combined effects of coronary atherosclerosis and cardiomegaly, with methylamphet…

Anzac Sullivan, a 38-year-old Aboriginal man, died of a cardiac arrhythmia secondary to severe underlying cardiac disease (coronary atherosclerosis, cardiomegaly, and possible QT prolongation) while fleeing from police a…

cardiologyforensic medicinedelaymethamphetamine
SAhospital2013-09-19

Coroner's Finding: HOCKING Robert Nicholas

67y · Male·aspiration pneumonia with contributing chronic schizophrenia

Robert Nicholas Hocking, a 67-year-old man with treatment-resistant chronic schizophrenia, died from aspiration pneumonia during his final hospitalization at Royal Adelaide Hospital. He was a long-term inpatient at Glens…

psychiatrygeneral medicineolanzapine
VICcommunity2023-09-21

Finding into death of Simaile Masila-Liutolo

35y · Male·Dilated cardiomyopathy and coronary atherosclerosis, in the setting of drug cons…

Simaile Masila-Liutolo, aged 35, died from cardiac arrhythmia precipitated by dilated cardiomyopathy and coronary atherosclerosis, compounded by acute methylamphetamine use and physical exertion during police apprehensio…

forensic medicinetoxicologymethamphetamine
NSW2022-03-18

Inquest into the death of Jeffrey Ellington

32y · Male·Subarachnoid haemorrhage due to ruptured cerebral aneurysm

Jeffrey Ellington, a 32-year-old Aboriginal male inmate, died suddenly from subarachnoid haemorrhage due to ruptured cerebral aneurysm while performing work duties at Long Bay Correctional Complex on 21 August 2020. Expe…

forensic medicineneurosurgerymethadone
TAShome2022-07-04

Coroner's Finding: Wallace., Vivienne Lorraine

73y · Female·atherosclerotic and hypertensive coronary vascular disease

Ms Wallace, a 73-year-old woman with hypertension and other comorbidities, developed atrial fibrillation during orthopaedic surgery for a fibula fracture. She was discharged on flecainide 50mg daily, metoprolol, and riva…

cardiologyorthopaedic surgeryflecainide
NThome2026-04-30

Inquest into the death of Baby S, Baby K, Baby B - (Co Sleeping)

Sudden Unexplained Death of an Infant (SUDI) in an unsafe sleeping environment; …

…ng is culturally important, modern sleeping environments with soft mattresses, blankets, alcohol use, and smoking create lethal risks absent from traditional practices. Systemic improvements needed include culturally au…

paediatricsmidwiferycommunicationsystemalcohol
VIChospital2024-05-28

Finding into death of Trevor Lindsay Jones

75y · Male·ruptured abdominal aortic aneurysm

A 75-year-old man with hypertension, diabetes, and smoking history presented to a regional emergency department with right lower quadrant abdominal pain, back pain,…

emergency medicinevascular surgerydiagnostic
19101115

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