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WA2025-11-28

Inquest into the Death of Cleveland Keith DODD

16y · Male·complications of ligature compression of the neck (hanging)

Cleveland Keith Dodd, aged 16, died on 19 October 2023 from complications of ligature compression of the neck (hanging) while in custody at Unit 18, a youth detention facility within Casuarina Prison, Western Australia. …

psychiatryemergency medicinediagnosticcommunication
VIChome2025-11-18

Finding into death of JZA

65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …

A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…

geriatric medicineinfectious diseasessystemcommunicationpholcodine
NSWhospital2025-11-17

Inquest into the death of Brooke Tiddy

32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…

A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…

bariatric surgeryanaesthesiadiagnosticcommunicationsevoflurane
VIC2025-11-10

Finding into death of Andrew Phillip John Kursinskis

57y · Male·Complications following food aspiration in a man with multiple co-morbidities

Andrew Kursinskis, a 57-year-old man with intellectual disability, dysphagia, autism, epilepsy and pica, died from complications following aspiration of chicken schnitzel while living in supported disability accommodatio…

speech pathologyemergency medicinesystemcommunicationlevetiracetam
SAhospital2025-11-05

Coroner's Finding: Jackson, Dennis Charles

67y · Male·Type 2 respiratory failure due to pneumonia

Dennis Jackson, a 67-year-old from Broken Hill, underwent left upper lobe lobectomy based on a falsely positive lung biopsy contaminated with squamous cell carcinoma tissue from another patient during processing at SA Pa…

cardiothoracic surgerypathologydiagnosticsystem
VIC2025-10-29

Finding into death of David James Klingberg

55y · Male·Complications of traumatic head injury sustained in a workplace incident (pallia…

David Klingberg, a 55-year-old experienced pile testing engineer, died from traumatic head injury sustained when an auxiliary line hook on a piling rig struck him in the face at a construction site. The hook became jamme…

emergency medicineintensive caresystemmorphine
VIChospital2025-10-28

Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …

Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarce…

infectious diseasesvascular surgerydiagnosticsystemantibiotics
QLDhospital2025-10-24

Non-Inquest findings into the death of Ms G

76y · Female·Head injury comprised of subdural haematoma, subarachnoid haemorrhage with brain…

A 76-year-old woman died from complications of a severe head injury sustained in a motor vehicle collision. She was initially managed conservatively at a regional hospital, but her condition deteriorated markedly at 9pm …

neurosurgeryemergency medicinecommunicationdelay
NT2025-10-24

Inquest into the death of Ebony Thompson

1y · Female·hypoxic brain injury caused by pressure to the neck from entrapment on a loop-to…

Ebony Thompson, aged 22 months, died from hypoxic brain injury caused by neck entrapment in a loop-topped chickencoop gate at a childcare centre. She became trapped while standing on a tricycle attempting to view chicken…

paediatricsemergency medicinesystemcommunication
QLDhospital2025-10-23

Inquest into the death of Shirley Elizabeth Haggett

78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…

78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…

anaesthesiaplastic and reconstructive surgerysystemdiagnosticmidazolam
QLDhome2025-10-17

Inquest into the death of Alexandria Catherine Forrester

39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…

A 39-year-old woman with opioid dependency died from methadone toxicity following cardiac arrest. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatmen…

addiction medicinegeneral practicediagnosticmedicationmethadone
VIChospital2025-10-15

Finding into death of Gary William Bruce

71y · Male·Complications following a right hepatic artery injury following an open cholecys…

A 71-year-old man with myelofibrosis and prior abdominal surgery died from complications of a right hepatic artery injury during open cholecystectomy for acute cholecystitis. The operative decision was reasonable and the…

general surgeryanaesthesiacommunicationsystem
VIChospital2025-10-10

Finding into death of Jeffrey George Nirens

70y · Male·intracranial haemorrhage secondary to haemorrhagic transformation of ischaemic s…

A 70-year-old man with chronic small vessel cerebral ischaemia died from intracranial haemorrhage following haemorrhagic transformation of an ischaemic stroke while in prison custody. He presented with acute stroke sympt…

neurologyemergency medicinemedicationsystemenoxaparin
QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…

emergency medicineinfectious diseasesdiagnosticdelayantacid
VIChospital2025-09-30

Finding into death of Robert Thoai Dao

73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…

A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…

paramedicineemergency medicinediagnosticprocedural
NSWmental health2025-09-29

Inquest into the death of BQ

23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging

BQ was a 23-year-old Aboriginal woman who died by hanging on the Paringa Ward at Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and bo…

psychiatryemergency medicinediagnosticcommunication
NSWhome2025-09-11

Inquest into the death of H GM

0y · Female·Unascertained

A 9-month-old girl died suddenly on 23 July 2018 following multiple head injuries from blunt force trauma sustained shortly before death. She had presented to medical practitioners multiple times in the preceding weeks w…

paediatricsemergency medicinediagnostic
VICcommunity2025-09-05

Finding into death of Lisa Nicole Murphy

52y · Female·unascertained - likely combination of underlying natural disease (myocardial inf…

Lisa Murphy, a 52-year-old woman with mental illness and substance use history, died following a physical altercation at a convenience store. She became involved in a verbal and physical confrontation with two women afte…

emergency medicineintensive carecommunicationrisperidone
NT2025-08-29

Inquest into the death of Raylene Dick, David Hardy and Karen Bading

46y · Female·Hepatic encephalopathy due to decompensated Child-Pugh C cirrhosis and meningiti…

This combined coronial finding examines three deaths at the Centre for National Resilience (CNR), a COVID-19 quarantine facility in Howard Springs. Ms Dick died from rapidly progressive melioidosis. David Hardy died from…

infectious diseasesintensive carediagnosticsystem
VIChospital2025-08-18

Finding into death of B T

53y · Male·Complications of hypoxic brain injury secondary to mixed drug toxicity (methylam…

BT, a 53-year-old man with substance use disorder and mental health conditions, died from complications of hypoxic brain injury secondary to mixed drug toxicity (methylamphetamine, benzodiazepines, metonitazene). He inje…

emergency medicineintensive caremethamphetamine

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