Coronial
VIChospital2026-01-23

Finding into death of MD

82y · Male·Complications of large bowel obstruction in a man with diverticular disease and …

An 82-year-old man died from complications of large bowel obstruction secondary to a sigmoid mass while incarcerated at Port Phillip Prison. He presented with abdominal pain and vomiting following a fall, and imaging con…

general surgerycolorectal surgerywarfarin
VIChospital2011-06-17

Finding into death of George Samuel Holmes

86y · Male·Cardiovascular disease in a man with subdural haemorrhage (in keeping with a fal…

…ge Samuel Holmes, an 85-year-old man with significant cardiovascular history (prior myocardial infarction, stroke, atrial fibrillation) on anticoagulation, collapsed in his prison cell on 4 April 2008. He sustained a sub…

cardiothoracic surgeryneurosurgerywarfarin
SAmental health2005-01-27

Coroner's Finding: ROBJOHNS Ronald Thomas

89y · Male·congestive cardiac failure due to ischaemic heart disease and aortic valve steno…

Ronald Thomas Robjohns, 89, died of congestive cardiac failure due to ischaemic heart disease and aortic valve stenosis while detained under the Mental Health Act at Glenside Hospital. He was admitted following severe de…

psychiatrygeriatric medicinesertraline
ACTcommunity2026-05-26

Inquest into the death of Donald Morley

93y · Male·Complications of invasive squamous cell carcinoma of the scalp

Donald Morley, aged 93, died at Claire Holland House hospice on 12 July 2024 while serving a nine-year sentence for murder. He was under 24/7 custodial supervision. The cause of death was complications of invasive squamo…

palliative carepsychiatry
NTcommunity2012-07-13

Inquest into the death of Master C

5y · Male·extensive skull fracturing and traumatic brain injury from pedestrian strike by …

A 5-year-old boy with significant disabilities from pneumococcal meningitis and stroke (right hemiparesis, hearing loss, epilepsy) was temporarily placed in care by the Department of Children a…

paediatricsneurologysodium valproate
NSW2023-07-24

Inquest into the death of Barry Faulkner

70y · Male·ischaemic and valvular heart disease with chronic pulmonary disease being a sign…

…dations for his multiple medical conditions including cerebrovascular disease, COPD, diabetes and previous stroke. Staff response to his collapse was appropriate and timely. The coroner found no evidence that alternative…

cardiologygeneral medicine
VIChospital2025-06-25

Finding into death of RFV

87y · Male·Consequences of an assault with severe facial fractures

…ped large cerebral infarcts. Despite resuscitation and ICU management, multi-organ failure and devastating stroke made neurological recovery unlikely. The coroner found the death resulted from criminal violence (murder c…

emergency medicineintensive caresystem
SAhospital2009-09-18

Coroner's Finding: VONDERWALL Frederick Albert

66y · Male·hepatorenal failure and biliary sepsis complicating common bile duct obstruction

A 66-year-old man incarcerated in Port Lincoln Prison died from hepatorenal failure and biliary sepsis complicating common bile duct obstruction. He presented with progressive jaundice, dark urine, and signs of liver fai…

general surgeryintensive care
NSW2025-11-19

Inquest into the death of Mark Lewis

86y · Male·End-stage congestive cardiac failure on a background of dilated cardiomyopathy

Mark Lewis, aged 86, died from end-stage congestive cardiac failure in custody at Long Bay Hospital Aged Care Unit. He had multiple chronic conditions (dilated cardiomyopathy, chronic kidney disease, diabetes, ischemic h…

cardiologyinfectious diseases
SAhospital2000-03-24

Coroner's Finding: JAMES Kevin

70y · Male·spontaneous left frontal intracerebral haemorrhage

…ve pulmonary disease, severe interstitial lung disease, and osteoporosis. In September 1998, he suffered a stroke and was appropriately transferred to hospital and recovered. In September, erratic behaviour prompted refe…

emergency medicineintensive care
QLDhospital2009-05-13

Tilse, Therese Josephine

91y · Female·Sub-dural haemorrhage due to head injury due to fall

A 91-year-old woman was admitted to hospital after accidental paracetamol overdose and was found to have had a recent right occipital lobe infarction. While receiving appropriate care, she fell from her hospital bed at t…

emergency medicineradiologyparacetamol
VIC2017-10-31

Finding into death of Andrew John Harman

49y · Male·Complications of heatstroke; Hyperthermia

A 49-year-old man died from heatstroke and hyperthermia while on a guided dirt bike tour in Hawaii. He consumed significant alcohol the previous …

emergency medicineintensive caredelay
VIC2017-12-01

Finding into death of Thuy Xuan Nguyen

52y · Male·Intracerebral haemorrhage

A 52-year-old man in remand custody at Port Phillip Prison was diagnosed with moderate hypertension in June 2015 and commenced on Ramipril. He experienced two periods of non-compliance with medication (July-August and Se…

neurosurgeryneurologycommunicationsystemramipril
SAcommunity2025-10-17

Coroner's Finding: Hall, Robert Lloyd

66y · Male·multiple injuries sustained in motor vehicle collision

…-sided visual field loss) who was not scanning to compensate for his disability. The driver had suffered a stroke in 2014 and was eventually issued an unrestricted licence after passing occupational therapy and licensing…

neurosurgeryneurologysystemcommunication
VIChospital2014-07-14

Finding into death of Mary Una Barnett

71y · Female·Diffuse Lymphoid Malignancy

Mary Una Barnett, a 71-year-old woman in custody at Dame Phyllis Frost Centre, died from diffuse lymphoid malignancy (high-grade lymphoma) discovered shortly before her death. She had extensive comorbidities including ch…

cardiologynephrologysystemdelay
NSWhospital2026-03-10

Inquest into the death of Mustafa Kayirici

31y · Male·metastatic alveolar soft part sarcoma

31-year-old man serving a custodial sentence died of metastatic alveolar soft part sarcoma on 25 January 2022. Diagnosed April 2020, the ultra-rare cancer (1 in 10 million incidence) had already metastasised at discovery…

oncologypalliative caredelaypazopanib
NThome2010-09-01

Inquest into the death of Michael Aubrey Campbell

20y · Male·acute heat stress (circumstances undetermined)

Michael Campbell, aged 20 months, died on 18 April 2008 from acute heat stress. He was placed in his bedroom cot by his mother after returning home from grandparents' house. He was found unconscious and extremely hot app…

forensic medicineemergency medicinesystem
VIChospital2019-03-20

Finding into death of Erika Maria Gerlach

79y · Female·Complications of injuries sustained in a motor vehicle collision (passenger)

…rib fractures, hepatic lacerations, and sternal fracture. Subsequent MRI revealed multiple brain infarcts (strokes), which significantly complicated her recovery. She developed aspiration pneumonia and died 22 days post-…

trauma surgeryneurosurgerysystemlevetiracetam
TASaged care2023-09-06

Coroner's Finding: Weldon, Dayle Patricia

93y · Female·Catastrophic subdural haemorrhage resulting from head strike sustained in a witn…

Dayle Patricia Weldon, a 93-year-old woman with dementia, fell in the secure suite of an aged care facility and sustained a catastrophic subdural haemorrhage from which she died three days later. The coroner found that M…

geriatric medicinegeneral practicebuprenorphine
TAShospital2019-10-29

Coroner's Finding: Holmes, Julie Anne

71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision

Julie Anne Holmes, aged 71, died of pneumonia following a cervical spine fracture sustained in a motor vehicle accident that was not diagnosed during her hospital admission. Critical clinical lessons include: (1) paramed…

emergency medicinegeneral surgerydiagnosticprocedural

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