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QLDhospital2025-06-26

Inquest into the death of Ivona Jovanovic

27y · Female·Gunshot wound to the chest

Ms Ivona Jovanovic, 27, died from a gunshot wound to the chest on 8 September 2019. The evidence indicates Mr Christos Panagakos inadvertently discharged a firearm while ascending stairs, striking Ms Jovanovic who was at…

trauma surgeryemergency medicineproceduralmethamphetamine
QLDhome2025-06-25

Non-inquest findings into the death of an eight month old twin whose family was known to Child Safety

0y · Male·Severe acute dehydration and acute malnutrition

An eight-month-old boy died from severe acute dehydration and malnutrition after receiving no or minimal fluid or food intake during a three-day drug binge by his mother and her partner. Child Safety was involved with th…

paediatricsemergency medicinediagnosticsystemmethamphetamine
VIChospital2025-06-25

Finding into death of RFV

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

RFV, an 87-year-old man, died from severe facial fractures and traumatic brain injury sustained during an assault by his daughter-in-law. He presented to hospital in critical condition with cardiac arrest, multiple facia…

emergency medicineintensive caresystem
VIChome2025-06-24

Finding into death of Jessica Geddes

27y · Female·Complications of multiple blunt force injuries

Jessica Geddes, 27, was killed by her partner Robert Rickerby through multiple blunt force injuries on 6 November 2020. The autopsy revealed extensive acute, subacute and chronic injuries inconsistent with accidental tra…

general practicepsychiatrydiagnosticsystemmethamphetamine
WAhome2025-06-24

Inquest into the Death of Leighton Michael WOOD

44y · Male·bronchopneumonia in the setting of combined drug effect

Leighton Wood, 44, died from bronchopneumonia in the setting of combined drug effect. He had schizoaffective disorder, anti-social personality disorder, and chronic polysubstance use disorder (alcohol, methylamphetamine,…

psychiatrypathologyzuclopenthixol decanoate
TAShospital2025-06-17

Coroner's Finding: de-identified RS

68y · Male·Exsanguination due to peptic ulcer of the duodenum with erosion into the gastrod…

A 68-year-old man presented to the emergency department with two episodes of fresh rectal bleeding and elevated blood urea. Despite stable vital signs, he was discharged after two hours with haemorrhoid suppositories and…

emergency medicinegastroenterologydiagnosticdelay
TASaged care2025-06-16

Coroner's Finding: McDonald, Maureen June

87y · Female·Terminal exacerbation of chronic obstructive pulmonary disease; antecedent cause…

Maureen 'Kitty' McDonald, 87, died from terminal exacerbation of COPD with an antecedent sacral pressure wound infection. She was admitted to residential aged care in October 2020 with a stage-two sacral pressure injury …

geriatric medicinegeneral practicesystemcommunicationantibiotics
TASaged care2025-06-13

Coroner's Finding: de-identified OQ -2

84y · Male·Head injury - left lateral convexity acute subdural haematoma with 2mm midline s…

An 84-year-old man with Parkinson's disease and moderate dementia was admitted to a rehabilitation unit after a fall at an acute hospital. He had been assessed as high falls risk and required a patient sitter at the acut…

geriatric medicinerehabilitation medicinecommunicationsystem
WA2025-06-12

Inquest into the Death of Graham John BUTLER

76y · Male·out-of-hospital cardiac arrest in a man with coronary artery atherosclerosis and…

Graham John Butler, aged 76, was a sentenced prisoner at Acacia Prison who died from out-of-hospital cardiac arrest caused by coronary artery atherosclerosis in the context of long-standing type 2 diabetes, hypertension,…

correctional healthgeneral medicinebenzydamine
SAhospital2025-06-11

Coroner's Finding: OHalloran, Emma Louise

48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam

A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…

cardiologygeneral practicesystemcommunicationflecainide
TAShospital2025-06-10

Coroner's Finding: Johnston, Trent Ian

40y · Male·aspiration pneumonitis with acute alcoholic hepatitis, pancreatitis, mixed drug …

Trent Ian Johnston, a 40-year-old man with a history of chronic paranoid schizophrenia, alcohol and substance abuse, died from aspiration pneumonitis complicated by mixed drug toxicity (codeine, morphine, diazepam, parac…

emergency medicineintensive carecodeine
WAcommunity2025-06-09

Inquest into the Death of Joyce Gladis CLARKE

29y · Female·gunshot wound to the abdomen

29-year-old Aboriginal woman (JC) of Ngarlawangga Yamatji Martu descent died from a gunshot wound inflicted by police on 17 September 2019. Four days prior, she was appropriately discharged from Sir Charles Gairdner Hosp…

psychiatryemergency medicinesystemmethamphetamine
VIChome2025-06-02

Finding into death of Christina Lackmann

32y · Female·Caffeine toxicity

32-year-old woman died from caffeine toxicity after ingesting caffeine tablets. She called 000 at 7:49 pm reporting dizziness and numbness but was triaged as non-urgent Code 3. Unable to connect with a secondary triage p…

emergency medicinetoxicologytriagesystemcaffeine
VIChospital2025-06-02

Finding into death of Julie Elizabeth Bruton

58y · Female·Aspiration pneumonia in association with rapidly progressive frontotemporal deme…

Julie Bruton, aged 58, died from aspiration pneumonia associated with rapidly progressive frontotemporal dementia and malnourishment. She was admitted to hospital on 17 December 2023 with acute respiratory distress and d…

palliative caregeriatric medicine
VIChome2025-05-30

Finding into death of Maxwell Brett Lawson

35y · Male·Stab wound to the back

Maxwell Brett Lawson, age 35, died from a stab wound to the back inflicted by Luke Blanchfield during an altercation at Blanchfield's home in Belgrave on 10 March 2024. Lawson attended the property to confront Blanchfiel…

forensic medicineemergency medicinemethamphetamine
NSWhospital2025-05-28

Inquest into the Death of Garry Small

71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …

A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…

emergency medicinegeriatric medicinemedicationdelayceftriaxone
NThospital2025-05-27

Inquest into the death of Child MS

4y · Male·Haemophilus influenzae septicaemia with superimposed respiratory tract infection

A 4-year-old previously healthy male presented to Katherine Regional Hospital on 10 September 2023 with fever and eye pain. He was examined, found to have tachycardia (HR 156) and fever (39.2°C), and diagnosed with viral…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
VIChospitalPodcast2025-05-26

Finding into death of Nancy Doreen Hay

99y · Female·Chest injuries in the setting of a tram incident (pedestrian)

A 99-year-old woman with dementia and reduced mobility was struck by a tram while crossing at a roundabout intersection in Essendon, Victoria. She sustained severe chest injuries including bilateral pneumothoraces, haemo…

emergency medicinetrauma surgerysystem
VIChospital2025-05-26

Finding into death of Shawn James Farlech

47y · Male·Pneumonia

Shawn Farlech, a 47-year-old man with acquired brain injury from childhood encephalitis living in specialist disability accommodation, died from pneumonia with sepsis. He presented with fever on 8 April and was initially…

general medicineintensive caresodium valproate
VIChome2025-05-21

Finding into death of Phillip Henry Reidy

27y · Male·Cyanide toxicity

Phillip Reidy, 27, died from cyanide toxicity after ingesting sodium cyanide during police arrest for a family violence incident. He had purchased 250g of sodium cyanide online from Bacto Laboratories using false informa…

forensic medicineemergency medicinecommunicationsystemsodium cyanide

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