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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
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
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
QLD2025-06-26

Non-inquest findings into the death of Peter Raymond Thistleton

61y · Male·Multiple injuries due to motor vehicle collision (driver)

A 61-year-old truck driver died in a heavy vehicle rollover on the Burnett Highway. Evidence indicates he experienced fatigue-related microsleep while driving at 04:45 hours, causing the prime mover to drift onto the roa…

cannabis
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
NSW2025-06-24

Inquest into the death of Scott Orrock

55y · Male·Multiple blunt force injuries

Scott Orrock, a 55-year-old experienced motorcyclist, died from multiple blunt force injuries following two successive motor vehicle collisions on the M4 Motorway westbound near the James Ruse Drive exit on 2 April 2020.…

system
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
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
NSWhome2025-06-24

Inquest into the death of Jade

3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…

Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…

paediatricspsychiatrydiagnosticcommunicationquetiapine
QLDhospital2025-06-20

Inquest into the death of Christopher Glen Essery

74y · Male·Sepsis secondary to fistulating Crohn's disease and post-surgery complications f…

Christopher Essery, a 74-year-old man with complex fistulating Crohn's disease, died from sepsis following surgery on 24 January 2019. He was transferred to Princess Alexandra Hospital (PAH) on 31 August 2018 for special…

colorectal surgerygastroenterologysystemcommunication
TASPodcast2025-06-19

Coroner's Finding: Findings in relation to Shane Navin, Leigh Mundy, Dennis Neagle and Anthony Seymour

Multiple causes: Shane Navin - drowning; Leigh Mundy and Dennis Neagle - multipl…

A comprehensive coronial inquest into four deaths at Targa Tasmania motorsport events (2021-2022). Shane Navin drowned after his vehicle crashed into a creek; Leigh Mundy and Dennis Neagle died in a high-speed crash due …

diagnosticsystemmirtazapine
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
ACTPodcast2025-06-13

Inquiry Into The Orroral Valley Fire

On 27 January 2020, an ADF MRH-90 Taipan helicopter ignited a fire in Namadgi National Park, ACT, during Defence Assistance to the Civil Community operations. The crew made an unplanned landing in the high-danger Orroral…

communicationsystem
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 Sam Phillip Chisholm LYNCH

27y · Male·effects of fire

Sam Lynch, aged 27, died from effects of fire while in remand at Hakea Prison on 5 March 2024. Following a dispute over undelivered canteen items, Sam set his mattress ablaze with a lighter. The response was catastrophic…

systemcommunicationdiazepam
SAhospital2025-06-12

Coroner's Finding: Salter, Kathleen Ethel

76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy

A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the com…

general surgeryanaesthesiadiagnosticproceduralapixaban
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
SA2025-06-03

Coroner's Finding: Sears, James Frank

53y · Male·disseminated malignant melanoma

A 53-year-old man died of disseminated malignant melanoma while incarcerated at Yatala Labour Prison. Initial excision of a large arm mole in November 2019 revealed Stage III melanoma. A January 2020 multi-disciplinary t…

dermatologyoncologycommunicationsystemdabrafenib

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