Coronial
QLDcommunity2016-12-08

Floyd, Leah Elizabeth

48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…

A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …

neurologypsychiatrycommunicationsystemdiazepam
NSWmental health2015-07-14

Inquest into the death of DA

34y · Male·Neck compression due to hanging

A 34-year-old man with a history of polysubstance abuse, high alcohol intake, and a recent suicide attempt died by hanging six weeks after being admitted to mental health services. Critical clinical lessons: (1) dual dia…

psychiatryemergency medicinediagnosticcommunicationmirtazapine
NSWhospital2025-08-14

Inquest into the death of Wilfred Whippy Williams

45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia

A 45-year-old Aboriginal man with poorly managed diabetes and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs i…

emergency medicineendocrinologycommunicationdiagnosticmetformin
WAcommunity2013

Inquest into the Death of Harris, Mr

74y · Male·Ischaemic heart disease in association with coronary artery atherosclerosis

Mr Harris, a respected Aboriginal elder aged approximately 74 years, died of ischaemic heart disease with coronary artery atherosclerosis while travelling bush alone on 2 February 2010. He bogged his vehicle, attempted u…

emergency medicinecardiologycommunicationsystem
QLDcommunity2020-04-17

Russo, Matthew Anthony

37y · Male·Cardiac failure due to sepsis due to bilateral bronchopneumonia

…ts were documented. No detailed social history was obtained despite multiple risk factors (obesity, heavy smoking, heavy alcohol use). International guidelines for assessing pneumonia severity were not applied. Dr S.'s …

general practicerespiratory medicinediagnosticcommunicationamoxicillin
NSWhome2017-06-30

Inquiry into the fire at 58 Surveyor Street

Male·Ignition of liquid petroleum gas pooled in bedroom by cigarette lighter

Mr Bowdi Latham suffered catastrophic 75% total body surface area burns when LPG pooling in a bedroom ignited from a lighter on 4 December 2014. Investigation revealed an open copper gas pipe in the granny flat had been …

diagnosticprocedural
WA2022-09-15

Inquest into the Death of Leslie SHORTTE

71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)

Leslie Shortte, a 71-year-old life prisoner, died from metastatic squamous cell carcinoma with complications. Critical failures in his prison medical care included: failure to complete annual health assessments after 201…

oncologypalliative carediagnosticcommunicationlidocaine
NThospital2018-06-19

Inquest into the death of Naomi Smith

26y · Female·Pulmonary embolism as a consequence of dislodged deep vein thrombosis

Naomi Smith, aged 26, died from pulmonary embolism caused by dislodged deep vein thrombosis while in ICU at Royal Darwin Hospital. She had complex mental health needs (BPD, PTSD, depression) and morbid obesity. The criti…

psychiatryintensive caresystemdelay
SAhospital2024-05-16

Coroner's Finding: Fisher, Lynne Patricia

60y · Female·sepsis due to community acquired pneumonia

Lynne Patricia Fisher, 60, presented to Mount Barker Hospital ED on 26 September 2018 with bilateral community-acquired pneumonia and was discharged after 6.5 hours despite clinical deterioration. She collapsed at home w…

emergency medicinegeneral practicediagnosticdelayamoxicillin/clavulanate
SAhome2024-06-28

Coroner's Finding: Evans, Caleb

0y · Male·unascertained, in an unsafe sleeping environment, on a background of respiratory…

Baby Caleb, aged 2 months, died on 30 November 2018 in an unsafe sleeping environment while his mother co-slept with him on a fold-out sofa in a squalid home. He had a concurrent respiratory tract infection. The coroner …

paediatricsgeneral practicesystemcommunication
WAhospital2017-08-23

Inquest into the Death of Marjorie Joy JARICK

54y · Female·Opioid toxicity (predominantly fentanyl)

54-year-old woman with diabetes, obesity, and multiple opioid allergies underwent groin surgery at a private hospital. Anaesthetist Dr Y. prescribed a 75mcg/hr fentanyl patch post-operatively for chronic pain management …

anaesthesiasurgerymedicationcommunicationfentanyl
SAhospital2006-05-19

Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…

77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural ta…

cardiologycardiothoracic surgerydiagnosticproceduralramipril
WAmental health2015-12-31

Inquest into the Death of Michael Ronald THOMAS

Unknown·Ruby: ligature compression of neck (hanging); Carly: ligature compression of nec…

Five young adults died by suicide within 12 months (March 2011 to March 2012), all connected to Alma Street Centre mental health services at Fremantle Hospital. Four were discharged (Ruby Nicholls-Diver, Carly Elliott, M…

psychiatryemergency medicinediagnosticcommunicationantidepressants
TAShome2025-06-24

Coroner's Finding: Infant W and Infant P

Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…

Two premature infants died from unsafe sleeping environments while in the care of their parents, despite being subject to child protection notifications. Infant W (4 months) died from asphyxia due to accidental overlay i…

paediatricspsychiatrydiagnosticcommunicationmethadone
VIChospital2025-01-10

Finding into death of William Thomas Gourley

39y · Male·Effects of fire (self-immolation)

William Gourley, a 39-year-old Aboriginal and Torres Strait Islander man with a long history of mental illness, depression, cannabis dependence, and psychosis, presented to the Latrobe Regional Hospital ED on 6 March 202…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
SAhospital2014-02-05

Coroner's Finding: COOK Eileen Hazel

76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…

Mrs Cook, a 76-year-old woman, died in January 2010 from hospital-acquired pneumonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangerously…

general practiceemergency medicinediagnosticcommunicationintravenous fluids
QLD2016-07-06

Mickelo, Garnett Allan

48y · Male·myocardial infarction due to coronary atherosclerosis (medically treated)

Garnett Mickelo, aged 48, died from myocardial infarction due to coronary atherosclerosis while in custody at Woodford Correctional Centre on 24 November 2012, shortly after discharge from Princess Alexandra Hospital fol…

cardiologycardiothoracic surgerymedicationcommunicationisosorbide mononitrate
QLDmental health2013-01-25

SH and AW

25y · Female·Chest injuries due to fall from height

Two psychiatric inpatients (SH, 25-year-old female; AW, 24-year-old male) died by suicide by jumping from the Buranda car park across from Princess Alexandra Hospital's Mental Health Unit within a 10-month period despite…

psychiatrydiagnosticcommunicationhaloperidol
WAmental health2015-12-31

Inquest into the Deaths Alma Street Centre

Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…

Five former psychiatric patients of Alma Street Centre (part of Fremantle Hospital) died between March 2011 and March 2012. Two died by suicide within 24 hours of discharge; one disappeared and was found deceased; one ab…

psychiatryemergency medicinediagnosticcommunicationantidepressants
SA2017-02-17

Coroner's Finding: MCPHERSON Lewis Mike

18y · Male·Gunshot wound to chest

An 18-year-old man (Lewis McPherson) was fatally shot by a 17-year-old (Liam Humbles) on New Year's Eve 2012. The coroner found the death was preventable. Humbles had illegally possessed a handgun for months, dealt drugs…

communicationsystemcannabis

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