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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
VIChome2025-02-27

Finding into death of Shayn Nathan Darmanin

43y · Male·Mixed drug toxicity (methadone, synthetic cannabinoids (5f-cumyl-pinaca and cumy…

Shayn Darmanin, a 43-year-old man with epilepsy, died from mixed drug toxicity involving methadone, synthetic cannabinoids, olanzapine, and duloxetine. He had a significant history of substance abuse, family violence off…

toxicologypsychiatrymethadone
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
VICaged care2025-01-06

Finding into death of C M

55y · Male·Diabetic ketoacidosis

CM, a 55-year-old man with severe congenital disabilities and Type 2 Diabetes, died from diabetic ketoacidosis while residing in a disability support facility. In the week preceding death, he experienced reduced appetite…

general practiceemergency medicinediagnosticlevetiracetam
TASaged care2024-11-18

Coroner's Finding: Bradburn, Lester Basil

73y · Male·Traumatic head, facial and chest injuries caused by fall down stairs at resident…

A 73-year-old man with Parkinson's disease and recent falls died from traumatic injuries after falling down six stairs while exiting a residential aged care facility at 5:00 AM. He had been admitted only 10 days prior an…

geriatric medicineneurologysystemcommunication
NSWhospital2024-10-11

Inquest into the death of AX

45y · Female·Multiple blunt force injuries

A 45-year-old woman with acute psychotic illness attended Prince of Wales Hospital ED on 4 August 2020 after presenting to police with persecutory delusions. She was assessed by mental health and medical clinicians who a…

emergency medicinepsychiatrydiagnosticcommunication
TAShome2024-08-09

Coroner's Finding: Mansell-Moore, Codie

17y · Male·epileptic seizure complicating idiopathic epilepsy

17-year-old Codie Mansell-Moore died from epileptic seizures on 10 December 2018. An ambulance was called at 6:09am while he was seizing, but paramedics staged around the corner and did not enter his home for 48 minutes …

emergency medicineparamedicinecommunicationsystemlevetiracetam
VIChospital2024-07-23

Finding into death of Laurence Maxwell Attwood

68y · Male·Ischaemic infarction of the right cerebral hemisphere and cerebellum due to thro…

A 68-year-old man died from ischaemic stroke (basilar artery and right posterior cerebral artery thrombosis) seven days after being struck by a motor vehicle while attempting to cross Warrigal Road, Hughesdale. The colli…

trauma surgeryneurosurgerysystem
VICcommunity2024-07-18

Finding into death of Frankie Skye Foulkes

0y · Female·Complications of spinal muscular atrophy

Frankie Skye Foulkes, a four-month-old diagnosed with spinal muscular atrophy type 1, died from complications of SMA while positioned in a standard car seat during a car journey. She had recently commenced nusinersen tre…

neurologyoccupational therapysystemnusinersen
QLD2024-06-18

Inquest into the deaths of Shiralee Deanne Tilberoo and Vlasta Wylucki

Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…

Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…

cardiologyaddiction medicineproceduralcommunicationdiazepam
VIChome2024-06-11

Finding into death of Martin Page

39y · Male·most likely suicide; possibly accidental death from untreated epilepsy or natura…

Martin Page, a 39-year-old man with epilepsy, schizophrenia or Asperger's syndrome, severe obsessive-compulsive behaviours, and intellectual disability, disappeared from his family home in October 2006 and has not been l…

psychiatryneurologysystemdelay
VIChome2024-05-20

Finding into death of Gwyn Pugh

63y · Male·Incised injuries to the neck and upper limbs

Gwyn Pugh, a 63-year-old man with longstanding bipolar affective disorder, died by suicide on 26 October 2022. He had been hospitalized for depression in April-May 2022 and received electroconvulsive therapy. Post-discha…

psychiatrygeneral practicecommunicationsystemmirtazapine
NSWcommunity2024-05-03

Inquest into the death of Keith Titmuss

20y · Male·exertional heat stroke

A 20-year-old professional rugby league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest aerobic fitness of hi…

sports medicineemergency medicinesystemdelaymidazolam
QLDhospital2024-04-22

Non-inquest findings into the death of Lenore

48y · Female·Hypoxic ischaemic encephalopathy due to pulmonary thromboembolism due to deep ve…

A 48-year-old woman with morbid obesity and smoking history presented to a rural hospital with severe hip and leg pain. Over five days across two hospitals, no venous thromboembolism (VTE) risk assessment was performed d…

emergency medicineorthopaedic surgerydiagnosticsystemoxycodone
VICaged care2024-02-29

Finding into death of P L

92y · Female·Consequences of an assault

A 92-year-old woman with dementia died from consequences of an assault by another resident with unmanaged psychosis in an aged care facility. The assault occurred after the facility failed to adequately monitor, assess, …

geriatric medicinepsychiatrydiagnosticcommunicationantipsychotic medication
VIChome2024-01-16

Finding into death of Kieran Joseph McGuinness

37y · Male·Sudden unexpected death in epilepsy (SUDEP) in the setting of acquired brain inj…

Kieran McGuinness, 37, died of sudden unexpected death in epilepsy (SUDEP) following acquired brain injury with post-traumatic epilepsy. He was found unresponsive on his apartment floor on 11 September 2022, having been …

neurosurgeryneurologydiagnosticcommunicationlevetiracetam
NTcommunity2024

Inquest into the death of Road Death 13 of 2024

77y · Male·Blunt force head and chest injuries from motor vehicle collision

A 77-year-old male with a history of seizures (2017, 2023) died from blunt force head and chest injuries sustained in a motor vehicle collision on 10 March 2024. The vehicle travelled at 157 km/h approaching a red traffi…

neurologycardiologysystemlamotrigine
VIChomePodcast2023-12-11

Finding into death of Shane Michael Tuck

38y · Male·hanging

Shane Tuck, an elite AFL player (2004-2013) and professional boxer (2015-2017), was found deceased by hanging on 20 July 2020. Post-mortem neuropathology confirmed severe stage III chronic traumatic encephalopathy (CTE).…

neurologypsychiatrycocaine
WAhome2023-11-10

Inquest into the Death of Child ML (Name Subject to Suppression Order)

7y · Female·Pneumonia complicating a viral respiratory illness with acute combined drug effe…

Child ML, aged 7, died of pneumonia complicating viral respiratory illness with acute combined drug effect. She had severe cerebral palsy with complex care needs including PEJ tube feeding and multiple medications. At th…

paediatricsrespiratory medicinemedicationsystemcodeine
TAScommunity2023-09-22

Coroner's Finding: Stein, Emily Catherine

22y · Female·Drowning secondary to epileptic seizure

Emily Catherine Stein, aged 22, died by drowning in Cataract Gorge on 25 January 2022. She had recently been diagnosed with epilepsy in May 2021, which was unstable at the time of death. While swimming with family, she d…

neurologyforensic medicineanti-epilepsy agents

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