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WAhospital2025-03-06

Inquest into the Death of Jalen Hunter NORRIS

23y · Male·Multiple injuries from being struck by train

Jalen Hunter Norris, aged 23, died by suicide when struck by a train on 9 April 2021. He was experiencing paranoid delusions and had recently been arrested for criminal damage and cannabis possession after an incident at…

emergency medicinepsychiatrycommunicationdiagnosticcannabis
VICcommunity2025-03-04

Finding into death of Andrea Dorothy Milner

55y · Female·Multiple injuries sustained in a train incident

Andrea Milner, a 55-year-old woman with cerebral palsy, depression, and anxiety, died from multiple injuries sustained when she drove her motorised wheelchair off a railway platform onto tracks at Ormond station on 23 Se…

psychiatrypsychologyescitalopram
VIChospital2025-03-03

Finding into death of Caroline Anne McCormack

74y · Female·Infective exacerbation of chronic obstructive airways disease in the setting of …

Caroline McCormack, 74, died from infective exacerbation of chronic obstructive airways disease following a medication administration error where pregabalin was erroneously included in her Webster-pak despite being cease…

general practicepalliative caremedicationsystempregabalin
NSW2025-02-28

Inquest into the death of Cameron De Vries

20y · Male·Drowning precipitated by a seizure

Cameron De Vries, a 20-year-old man with severe autism spectrum disorder and global developmental delay, died by drowning precipitated by a seizure in a bathtub at a disability support home. He had experienced a seizure …

emergency medicineneurologydiagnosticsystemranitidine
VICmental health2025-02-27

Finding into death of Judith Mary Pollard

73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…

Judith Pollard, a 73-year-old woman with an extensive mental health history, was voluntarily admitted to Shepparton Private Hospital on 1 June 2023 following acute depression and paranoia. Despite her family informing st…

psychiatryemergency medicinesystemcommunicationamitriptyline
VIChospital2025-02-27

Finding into death of Steven John Parlby

73y · Male·Complications of multiple injuries sustained in a motor vehicle incident (car vs…

A 73-year-old man with extensive medical comorbidities including severe biventricular heart failure, COPD, sleep apnoea, and hypertension experienced a medical episode while driving, causing him to cross into oncoming tr…

general practicecardiologysystemcommunicationvalsartan
ACThospital2025-02-26

Inquest Into The Death Of Jessica Hilary Bovill

43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…

A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…

emergency medicinetoxicologymedicationcommunicationamitriptyline
TAScommunity2025-02-21

Coroner's Finding: Allford, Mary Kathleen; Foster, Trevor Allan; Watson, Peter John

Female·drowning (all three deceased)

This coronial finding examined three flood-related deaths in Tasmania during June 2016 following exceptional rainfall. Mary Allford drowned when her Latrobe home was inundated; Trevor Foster was swept away at Ouse; Peter…

emergency medicinepublic healthcommunicationsystem
VIChospital2025-02-21

Finding into death of Douglas George Coyle

62y · Male·Complications of likely sepsis in the setting of a pseudo bowel obstruction in a…

Douglas Coyle, a 62-year-old man with Hirschsprung's disease, intellectual disability, and epilepsy, died from sepsis complicating pseudo bowel obstruction. He presented to hospital on 15 June with shortness of breath, r…

general practiceemergency medicinedelay
NSWhospital2025-02-21

Inquest into the death of David Freeman

46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…

A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…

emergency medicinegeneral practicediagnosticmedicationaspirin
VIC2025-02-19

Finding into death of Mark Fava

46y · Male·Coronary artery disease

Mark Fava, 46, died of coronary artery disease while in custody at Port Phillip Prison. He was found unresponsive in his cell and CPR was commenced immediately, continuing until paramedic arrival. The death was from natu…

emergency medicinecorrectional healthamitriptyline
NSWhospital2025-02-17

Inquest into the death of IE

27y · Male·Multiple blunt force injuries from jumping off a cliff

A 27-year-old involuntary mental health patient absconded from a hospital transfer vehicle and subsequently died by jumping from a cliff. Critical failures included: absence of clinical assessment before transfer despite…

psychiatryemergency medicinediagnosticcommunicationvenlafaxine
NTmental health2025-02-14

Inquest into the death of Pukumani

47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…

Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…

psychiatryemergency medicinediagnosticcommunicationketamine
TAS2025-02-14

Coroner's Finding: Walker, Danielle Kate

26y · Female·Multiple head, chest and limb injuries sustained in a motor vehicle crash

Danielle Kate Walker, a 26-year-old experienced driver, died in a head-on motor vehicle collision on Boyer Road, Tasmania on 3 June 2023. The crash was caused entirely by the driver of the other vehicle, Graham John Free…

emergency medicineforensic medicinemethamphetamine
VIChome2025-02-14

Finding into death of Martin Barlow

67y · Male·Head injuries sustained in falls

Martin Barlow, 67, died from head injuries sustained in two falls on 5 August 2022 while intoxicated (BAC 0.17 g/100mL). He suffered subarachnoid haemorrhage and subdural haemorrhage. After Ms Burrell called emergency se…

emergency medicineparamedicinedelaysystemalcohol
VIChospital2025-02-13

Finding into death of Jack Brownlee

21y · Male·Complications of injuries sustained when a trench wall collapsed

Jack Brownlee, 21, died from crush injuries sustained in a workplace trench collapse at a construction site. Despite family concerns that excavator use during rescue exacerbated his injuries, expert geotechnical and resc…

emergency medicinetrauma surgerysystemmidazolam
VIChospital2025-02-12

Finding into death of Alexander Cameron

40y · Male·Aspiration pneumonia

Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia f…

intensive caregeneral surgeryclozapine
VICaged care2025-02-12

Finding into death of Donald Walter Thoms

90y · Male·Complications following aspiration of food

Donald Walter Thoms, 90 years old with intellectual disability and high aspiration risk, died from complications following aspiration of food while in specialist disability residential care. He was on a pureed diet and t…

palliative careemergency medicine
VIChomePodcast2025-02-11

Finding into death of Kathleen Dawn Arnold

30y · Female·Acute ethanol toxicity on a background of chronic alcoholism

Kathleen Arnold, aged 30, died from acute ethanol toxicity on a background of chronic alcoholism. She had a 20-year history of alcohol dependence, complex trauma from a childhood near-drowning incident, eating disorders,…

addiction medicinepsychiatrysystemalcohol
VIChome2025-02-07

Finding into death of T

15y · Male·Combined heroin and methamphetamine toxicity

T, a 15-year-old boy subject to a Care by Secretary Order, died from combined heroin and methamphetamine toxicity on 24 November 2019. He had experienced multiple placement instability (over 20 placements in two years), …

paediatricspsychiatrycommunicationsystemheroin

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