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VIChome2025-08-07

Finding into death of Emma Louise Terrill

41y · Female·Aspiration pneumonia in the setting of a mixed drug toxicity

Emma Terrill, 41, died from aspiration pneumonia in the setting of mixed drug toxicity. Post-mortem toxicology revealed elevated tramadol with benzodiazepines (alprazolam, diazepam, temazepam, oxazepam) causing synergist…

general practicepsychiatrysystemtramadol
TAShome2025-08-05

Coroner's Finding: Iliev, Patricia

57y · Female·starvation due to insufficient food intake

Patricia Iliev, a 57-year-old woman, died from starvation after progressively restricting her food intake over months while immobilised by chronic back pain. She had a gastrointestinal stromal tumour and advanced lung di…

general practicepsychiatrysystemdelayaspirin
VIChospital2025-08-04

Finding into death of Winifred Jean Carpenter

82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…

Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…

general surgerycolorectal surgerydiagnosticcommunication
VICcommunity2025-08-04

Finding into death of Moustafa Aboueid

28y · Male·Head injuries sustained in an electric scooter incident

A 28-year-old man died from head injuries sustained when he lost control of a high-powered electric scooter (Kaabo Mantis 10 Elite, dual 1000W motors, 65 km/h capable) while riding at 50-60 km/h on a residential road. He…

NTcommunity2025-08-01

Inquest into the death of Grace Moulding

27y · Female·Multiple blunt force injuries in the context of a single vehicle rollover

Grace Moulding, a 27-year-old British woman, died in a single-vehicle rollover on the Sandover Highway while driving an unregistered Art Centre vehicle at an estimated 116 km/h on an unsealed road. Critical failures incl…

occupational and environmental healthemergency medicinesystemcommunication
SAhospitalPodcast2025-07-31

Coroner's Finding: Panella, Anna Vincenza and Skeffington, Bernard Anthony and Jessett, Graham Henry

Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…

Three South Australians died following extended waits on ambulance ramps outside metropolitan hospitals. Anna Panella (76) died from pulmonary thromboembolism; Bernard Skeffington (89) died from aspiration pneumonia afte…

emergency medicinecardiologycommunicationsystem
QLDPodcast2025-07-31

Inquest into the Cause and Circumstances surrounding the death of RICKIE JAMES MAKIN

44y · Male·Drowning due to head injury due to impact with yacht

Rickie James Makin, 44, fell overboard from the 44.7-foot racing yacht Lady Helena in heavy seas during a competitive yacht race on Moreton Bay, Queensland, on 7 March 2020. He was not wearing a personal flotation device…

systemdelaytemazepam
QLDhome2025-07-31

Inquest into the death of Jordan Robert Crocker

25y · Male·Electrocution

Jordan Robert Crocker, a 25-year-old qualified electrician, was fatally electrocuted in a roof space while diagnosing a U4 fault code on a Daikin ducted air conditioner system. The circuit supplying the air conditioner w…

occupational and environmental healthsystemcommunication
NSWhome2025-07-30

Inquest into the death of Hilary Gordon-Squire

65y · Male·Pneumonia, due to chronic lung disease with atherosclerotic cardiovascular disea…

A 65-year-old man with severe chronic lung disease, COPD, and coronary artery disease died at home. Evidence suggests he deliberately ingested benzodiazepines and possibly other substances in a self-harm attempt. However…

forensic medicinegeneral practicesystemdelaybenzodiazepines
VIChome2025-07-30

Finding into death of William Charles Heddergott

50y · Male·plastic bag asphyxia in the setting of ethanol intoxication and blunt force head…

William Heddergott, 50, died from asphyxiation with head injuries while intoxicated, in circumstances suggesting his mother Erica (who pleaded guilty to murder) perpetrated fatal family violence. Clinical lessons include…

psychiatrypsychologycommunicationsystemalcohol
VIChospital2025-07-30

Finding into death of YTR

78y · Female·Complications of prolonged immobility and malnutrition in a woman with retroperi…

A 78-year-old woman with schizophrenia, depression, and undiagnosed retroperitoneal lymphoma died from septic shock complicating severe pressure ulcers, malnutrition, and dehydration. She had been immobile on a couch for…

geriatric medicineintensive caredelaysystemasenapine
VIChospital2025-07-30

Finding into death of MHT

86y · Male·Complications of blunt force trauma in a man with cardiac amyloidosis and athero…

An 86-year-old man with dementia, cardiac amyloidosis and atherosclerotic cardiovascular disease died from complications of blunt force trauma sustained in an assault by his adult son. The deceased had been diagnosed wit…

emergency medicineneurosurgerysystemcommunicationondansetron
VIChome2025-07-28

Finding into death of Aluel Ajak

9y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian)

Aluel Ajak, a 9-year-old girl with autism spectrum disorder, severe developmental delay, and moderate intellectual disability, died from injuries sustained when struck by a motor vehicle after absconding from her home. S…

paediatricsdisability medicinesystemdelayclonidine
VIChome2025-07-28

Finding into death of GVY

43y · Female·Head and neck injuries

GVY, aged 43, was fatally attacked by her husband MJN with an axe and knife on 3 December 2022 after she initiated separation. MJN had a documented history of coercive control, physical violence, jealousy, and financial …

systemdelay
VIChome2025-07-28

Finding into death of Heather Ida Simone Calgaret

30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…

Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …

general practiceaddiction medicinemedicationdiagnosticbuprenorphine
NSW2025-07-24

Inquest into the death of PF

45y · Male·Hanging

PF, aged 45, died by hanging in custody at South Coast Correctional Centre following bail refusal and adverse legal advice. The coroner found his death was intentional self-harm. Although PF had a significant history of …

psychiatrypsychologydelay
VICmental health2025-07-24

Finding into death of Mr SWX

32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity

A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …

psychiatryemergency medicinemedicationcommunicationolanzapine
VIChome2025-07-24

Finding into death of Jill Hughes

75y · Female·Infective complications of a left hand injury with diabetic ketoacidosis

A 75-year-old woman died from infective complications of a left hand wound sustained in a fall from a ladder in November 2023, complicated by undiagnosed diabetic ketoacidosis. Despite family encouragement to seek medica…

infectious diseasesendocrinologydelaydiagnostic
VICaged care2025-07-24

Finding into death of Silvie Marion Burton

89y · Female·Acute upper airway obstruction by food bolus

An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significant discrepancies between reported actions and actua…

geriatric medicineemergency medicineproceduraldelaycitalopram
WAhome2025-07-23

Inquest into the Death of Lynn Marie CANNON

51y · Female·Multiple sharp force injuries to the chest

Lynn Marie Cannon, 51, was murdered by her estranged husband Paul Cannon on 5 December 2022 at his residence. After ending their 25-year marriage characterised by coercive control, she had begun a new relationship. When …

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