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VIChospital2025-07-15

Finding into death of Linda Snadden

62y · Female·Aspiration pneumonia in the setting of refractory focal status epilepticus

Linda Snadden, a 62-year-old woman with cognitive decline, brain tumour history, and multiple comorbidities including severe sleep apnoea and pulmonary hypertension, died from aspiration pneumonia during refractory focal…

neurologyneurosurgeryanti-seizure medications
QLDhospital2025-07-14

Non-inquest findings into the death of a two year old girl whose family was known to Child Safety

2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection

A two-year-old girl died from complications of severe iron-deficiency anaemia and COVID-19 infection. She had significant feeding difficulties, took almost exclusively milk and yoghurt, and was profoundly anaemic with po…

paediatricsemergency medicinediagnosticdelaymethamphetamine
VICmental health2025-07-14

Finding into death of Maxwell Bernard Howard

84y · Male·Bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart di…

Maxwell Howard, 84, died from bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart disease while admitted to a mental health acute unit under a Temporary Treatment Order. He had multiple comorbid…

psychiatryemergency medicinecarbamazepine
WAcommunity2025-07-09

Inquest into the Death of Travis Barry Mark Kimberly HART

33y · Male·Heat stroke (environmental exposure) in a man with methylamphetamine effect

Travis Hart, 33, died from heat stroke with methylamphetamine effect after abandoning a vehicle during a police intercept in bushland near Kalgoorlie on 25 December 2022. He became separated from companions and was found…

emergency medicineforensic medicinedelaycommunicationmethamphetamine
VIChospital2025-07-08

Finding into death of KD

48y · Female·Combined effects of cardiac hypertrophy, chronic obstructive pulmonary disease a…

KD, a 48-year-old woman with chronic schizo-affective disorder, end-stage renal failure, COPD, cardiac hypertrophy and obesity, died from combined natural causes while under assessment order in psychiatric care. She pres…

psychiatryintensive careolanzapine
NTcommunity2025-07-07

Inquest into the death of Kumanjayi Walker

19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …

Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…

emergency medicinegeneral practicediagnosticprocedural
VIChospital2025-07-07

Finding into death of Gregory Walter Heenan

66y · Male·acute myocardial infarction due to coronary artery atherosclerosis

Gregory Walter Heenan, a 66-year-old man with intellectual disability living in Specialist Disability Accommodation, was admitted to hospital on 12 April 2025 with vomiting and was diagnosed with ST-elevated myocardial i…

cardiologyemergency medicine
TAScommunity2025-07-04

Coroner's Finding: de-identified PD

41y · Male·Chest and limb injuries resulting from deliberately jumping from the Tasman Brid…

A 41-year-old male with schizophrenia, depression, and PTSD died by suicide by jumping from the Tasman Bridge. He had a long history of methamphetamine use and psychotic episodes, with multiple involuntary mental health …

psychiatryemergency medicinemethamphetamine
TAScommunity2025-07-04

Coroner's Finding: de-identified KT

26y · Male·multiple injuries, primarily severe chest trauma, due to jumping from the Tasman…

A 26-year-old man with psychosis and acute schizophrenia died by suicide jumping from the Tasman Bridge. He had been diagnosed with ADHD, generalised anxiety disorder, and sleep-wake disorder in 2021, with subsequent psy…

psychiatryemergency medicinepaliperidone
TAS2025-07-04

Coroner's Finding: de-identified CF

24y · Male·blunt trauma and drowning due to intentional jumping from Tasman Bridge

A 24-year-old male international student and graduate employee experienced his first acute psychotic episode in December 2022, triggered by workplace stress and unsubstantiated beliefs about colleague manipulation. Initi…

psychiatryemergency medicinedelaycommunicationolanzapine
VIChome2025-07-04

Finding into death of Joan Pauline Skillen

93y · Female·Pneumonia

Joan Pauline Skillen, a 93-year-old woman with intellectual disability residing in specialist disability accommodation, died from pneumonia. She had dysphagia and multiple comorbidities. Initial symptoms (milky discharge…

general practicepalliative careantibiotics
VIChospital2025-07-04

Finding into death of Geoffrey David Thorn

62y · Male·urosepsis

Geoffrey Thorn, a 62-year-old man with intellectual disability, Lennox-Gastaut syndrome, and cerebral palsy, died from urosepsis following emergency urological surgery for a kidney stone. He presented to hospital with fe…

emergency medicineurology
VIC2025-07-04

Finding into death of Brent Reker

35y · Male·Hanging

Brent Reker, a 35-year-old prisoner with extensive history of suicide attempts (including hanging, overdose, and self-harm), died by hanging in Forbes Unit at Ravenhall Corrections Centre on 12 December 2019, approximate…

psychiatryemergency medicinecommunicationsystemmethadone
VIChospital2025-07-03

Finding into death of JV M

19y · Female·multiple injuries sustained in a train incident

JVM was a 19-year-old with major depressive disorder, anxiety, and possible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St …

psychiatryemergency medicinecommunicationsystemsertraline
VIChome2025-07-03

Finding into death of Stephanie Rebernik

69y · Female·Effects of fire

Stephanie Rebernik, aged 69, died in a house fire in 2023. She had an acquired brain injury from 1980 with cognitive decline, poor risk identification, and a documented five-year history of unsafe fire-lighting behaviour…

occupational therapypsychiatrysystemdelayoxazepam
WAcommunity2025-07-02

Inquest into the Death of Donald Joseph Hemara WARD

50y · Male·Multiple injuries sustained in high-speed motorcycle crash

Donald Ward, aged 50, died from multiple injuries sustained in a high-speed motorcycle crash on 4 March 2023 in Karratha, WA. Ward left a nightclub intoxicated with alcohol (BAC 0.186%) and cannabis, obscured his number …

paramedicineemergency medicinepossibly diagnosticalcohol
TAShospital2025-06-30

Coroner's Finding: Cameron, Hugh Hutton

88y · Male·acute traumatic left cerebral convexity subdural haematoma

An 88-year-old man with age-related cerebral atrophy fell at home on 10 August 2022, injuring his thumb. He presented to the ED alert and orientated, denying head strike or loss of consciousness. His thumb dislocation wa…

emergency medicineforensic medicine
TAScommunity2025-06-30

Coroner's Finding: de-identified IB

21y · Male·drowning

A 21-year-old male with schizophrenia and cannabis use died by suicide after jumping from the Tasman Bridge. He had been admitted to Royal Hobart Hospital on 7 May 2019 with suicidal ideation and auditory hallucinations …

psychiatryemergency medicinearipiprazole
TAScommunity2025-06-30

Coroner's Finding: de-identified XA

41y · Male·head and chest injuries from fall from height

A 41-year-old man with schizophrenia died by suicide, jumping from the Tasman Bridge on Christmas Eve 2022. He had a 15-year history of mental illness with multiple suicide attempts, previously managed with antipsychotic…

psychiatrygeneral practicesystemdelaypaliperidone
WAhospital2025-06-30

Inquest into the death of Houston PEEL

29y · Male·ligature compression of the neck (hanging)

Houston Peel, a 29-year-old man, presented to Fiona Stanley Hospital ED at 4:35 am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation fol…

emergency medicinepsychiatrycommunicationdelayolanzapine

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