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VICcommunity2025-10-14

Finding into death of Shuyang Wang

24y · Male·Drowning

Shuyang Wang, a 24-year-old international student from China, drowned at Rosebud Beach on 28 December 2023 after entering the water on an improperly inflated kayak without a personal flotation device. Wang was unable to …

VICaged care2025-10-10

Finding into death of Christopher Kuric

52y · Male·Aspiration pneumonia in a man with end stage Huntington's disease

Christopher Kuric, a 52-year-old man with end-stage Huntington's disease residing in specialist residential care, died of aspiration pneumonia. He had documented swallowing difficulties managed by speech pathology and di…

neurologypalliative carepossibly_preventabledelay
VIChospital2025-10-10

Finding into death of Jeffrey George Nirens

70y · Male·intracranial haemorrhage secondary to haemorrhagic transformation of ischaemic s…

A 70-year-old man with chronic small vessel cerebral ischaemia died from intracranial haemorrhage following haemorrhagic transformation of an ischaemic stroke while in prison custody. He presented with acute stroke sympt…

neurologyemergency medicinemedicationsystemenoxaparin
QLDhome2025-10-10

Inquest into the death of AB

31y · Male·Hanging

31-year-old male with borderline personality disorder, alcohol use disorder, and history of self-harm died by hanging. He had multiple presentations to emergency services and mental health services from March to July 202…

psychiatrygeneral practicesystemcommunicationalcohol
VIChome2025-10-09

Finding into death of Narelle Catherine Simmons

42y · Female·Haemothorax and pneumonia in the setting of acute and chronic chest injuries and…

Narelle Simmons, 42, died from haemothorax and pneumonia secondary to rib fractures, with contributing factors of hepatic cirrhosis, chronic alcoholism, and multiple drugs (methadone, methylamphetamine, diazepam, sertral…

forensic medicinegeneral practicediagnosticcommunicationmethadone
QLDhospital2025-10-08

Inquest into the death of Janis Ellen Doherty

57y · Female·Multi-organ failure due to drug-induced liver injury caused by sodium valproate …

Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nau…

neurologyhepatologydiagnosticmedicationsodium valproate
VICcommunity2025-10-07

Finding into death of Vignesh Choudary Khilari

20y · Male·Head, chest, pelvic and leg injuries sustained in a motor vehicle incident (moto…

A 20-year-old learner motorcyclist died from traumatic injuries sustained in a collision with a power pole while accelerating aggressively on a public road. The rider was inexperienced (obtained learner permit 4 months p…

cannabis
VIC2025-10-07

Finding into death of Anthony George Creaton

55y · Male·Acute myocardial infarction secondary to coronary artery thrombosis due to coron…

Anthony Creaton, 55, died of acute myocardial infarction due to coronary artery thrombosis and atherosclerosis in prison custody. He presented with chest pain on 13 November 2022 (twice) and again on 14 November, but nur…

cardiologygeneral practicediagnosticcommunicationgliclazide
TAS2025-10-07

Coroner's Finding: de-identified AL

16y · Male·Multiple chest, abdominal and pelvic injuries from quad bike crash; specifically…

A 16-year-old male died from massive chest, abdominal and pelvic injuries sustained in a quad bike crash. The quad bike's right rear wheel detached during riding due to incorrect fitting of after-market wheels using wron…

forensic medicineemergency medicineprocedural
VIChome2025-10-06

Finding into death of Ivy Bella Roze Egan-Lee

4y · Female·Hypoxic ischaemic encephalopathy following immersion

A 4-year-old girl drowned in a neighbouring pool after crawling through a gap in a shared boundary fence that served as a pool safety barrier. The fence had been certified as compliant in February 2024 but deteriorated s…

systemfentanyl
NSWhome2025-10-03

Inquest into the death of Dima Thomson

39y · Male·multiple gunshot wounds

Dima Thomson, a 39-year-old man with a history of alcohol-fuelled domestic violence incidents and mental health conditions, died from multiple gunshot wounds after police attended his home responding to a breach of an ap…

forensic medicinecommunicationsystemalcohol
VICcommunity2025-10-02

Finding into death of Frances Jeyann Ramirez

22y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian vs. car)

Frances Jeyann Ramirez, a 22-year-old student, was fatally struck by two vehicles while crossing Hopkins Street in Footscray on 25 November 2023. She sustained multiple injuries and died at the scene. The coroner found t…

system
QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…

emergency medicineinfectious diseasesdiagnosticdelayantacid
VIC2025-10-01

Finding into death of Alicia Jade Montebello, Joshua Elmes, Megan Fox, Lucus Garzoli

Unknown·Injuries sustained in a motor vehicle incident

Four young people died in a single-vehicle motor vehicle collision on 27 May 2023. Jorja Fox (16, learner driver) was driving Alicia Montebello's vehicle at excessive speed when she lost control on a rural road. The vehi…

VICcommunity2025-09-30

Finding into death of Viet Quy Dinh

39y · Male·Drowning

A 39-year-old man drowned while snorkelling at Altona Beach wearing a 10.95 kg weight belt without fins or buoyancy compensation device. He became fatigued in deep, choppy water with poor visibility. The coroner found th…

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
NSWmental health2025-09-29

Inquest into the death of BQ

23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging

BQ was a 23-year-old Aboriginal woman who died by hanging on the Paringa Ward at Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and bo…

psychiatryemergency medicinediagnosticcommunication
VIChospital2025-09-25

Finding into death of Dio Miranda Katiana Kemp

3y · Female·Streptococcus pyogenes septicaemia

A three-year-old girl with Down syndrome died from Group A Streptococcus septicaemia after a 10-day illness. She presented four times to hospital (ED and rapid review clinic) over three days with fever, rash, and diarrho…

emergency medicinepaediatricsdiagnosticcommunication
NSWcommunity2025-09-24

Inquest into the death of Matthew Richard Lothian

37y · Male·self-inflicted gunshot wound to the head and neck

Matthew Lothian, aged 37, died from a self-inflicted gunshot wound to the head and neck on 6 January 2021 in Wollongong. He was on medical escort from custody when he seized the firearm from Correctional Services Officer…

psychiatrycorrectional healthsystemcommunicationmethadone
VIC2025-09-24

Finding into death of Bryan Pham

24y · Male·multiple injuries and chest compression asphyxia (train strike)

Bryan Pham, 24, died by suicide via train strike on 2 June 2020, two days after release from remand custody. He had schizophrenia, substance use disorder, and was recently incarcerated for assault and FVIO breach. While …

psychiatrycorrectional healthcommunicationsystemmethamphetamine

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