Coronial
VIChospital2025-10-17

Finding into death of Rachel Frances Piskun

42y · Female·Pneumonia, underlying severe cerebral palsy

…ion stockings were left on continuously for three days causing severe tissue damage requiring below-knee amputation. Systemic failures included inadequate pain assessment in a non-verbal patient, poor communication betwe…

emergency medicinegeneral medicinediagnosticmedicationmorphine
SA2011-02-09

Coroner's Finding: MADELEY Daniel Nicholas

18y · Male·respiratory failure secondary to closed chest trauma

… injuries including flail chest with bilateral rib fractures, pulmonary fat embolism, and bilateral foot amputation. The coroner found the death entirely preventable—a replacement machine with safety interlocks was purch…

occupational and environmental healthsystemdelay
SAaged care2010-05-14

Coroner's Finding: HUTTON Arthur John

87y · Male·asphyxia due to neck entrapment between bedpole and mattress

An 87-year-old man with dementia and a history of falls died from asphyxia when his neck became entrapped between a bedpole and the mattress after falling from bed in an aged care facility. The bedpole was positioned uno…

geriatric medicineoccupational therapysystemprocedural
TAS2022-02-05

Coroner's Finding: Hosking, Leigh Mathew

39y · Male·multiple injuries sustained in a single motor vehicle crash

39-year-old male died from multiple injuries sustained in a single motor vehicle crash. He was driving without a licence, not wearing a seatbelt, and under the influence of alcohol (BAC 0.217 g/100mL, over four times the…

alcohol
TAShospital2020-07-27

Coroner's Finding: McNeair, Jacqueline

79y · Female·subdural haematoma following mechanical fall with head strike

…d woman with multiple comorbidities including diabetes, peripheral neuropathy, and previous partial foot amputation fell backwards in a hospital toilet on 23 November 2018, striking her head on a sink and floor. She sust…

emergency medicinegeneral medicine
SAaged care2016-08-22

Coroner's Finding: SCHULZ Bertha Anna

89y · Female·Multiple organ failure with cachexia on a background of chronic lower limb ulcer…

…y 2013 for deteriorating ulcers and behavioral changes concerning for dementia. Despite consideration of amputation, conservative wound management was pursued as clinicians deemed her unsuitable for surgery. The inquest …

geriatric medicinegeneral medicine
WAcommunity2019-11-15

Inquest into the Suspected Death of Brian Anthony DUFFY

52y · Male·Drowning in Falcon Bay

Brian Anthony Duffy, a 52-year-old man with multiple serious chronic conditions including osteoarthritis, diabetes, liver dysfunction from alcohol abuse, and peripheral vascular disease requiring bypass surgery, disappea…

WA2015-09-16

Inquest into the Death of Sean BRUCE

18y · Male·Multiple injuries sustained in motorcycle crash

Sean Bruce, 18, died from multiple injuries sustained in a motorcycle crash on 17 May 2012. He was riding a stolen motorcycle at excessive speed (90-134+ km/h in a 60 km/h zone) when he lost control at a roundabout. He h…

emergency medicinetrauma surgerymethamphetamine
NThome2001-03-09

Inquest into the death of Sebastian Barry Davis

10y · Male·Septic arthritis of the left shoulder with acute heart failure resulting from to…

…y to sweat and lack of pain sensation, leading to multiple serious complications including bilateral leg amputations and recurrent infections. He was in state care under Family, Youth & Children's Services and placed wit…

paediatricsinfectious diseases
SA2011-12-22

Coroner's Finding: FRY Lindsay Allan

61y · Male·ischaemic heart disease with significant atherosclerotic narrowing of all three …

Lindsay Allan Fry, a 61-year-old prisoner with poorly controlled Type II diabetes, died of ischaemic heart disease while in custody at Yatala Labour Prison. Autopsy revealed marked coronary artery atherosclerosis, myocar…

cardiologyendocrinologymetformin
NTcommunity2013-03-22

Inquest into the death of Jennifer Taylor and Clifford Norman

27y · Male·Blunt head trauma and severe multiple injuries sustained in a single motor vehic…

… passenger Jennifer Taylor (15) died from severe injuries including spinal cord damage and bilateral leg amputation. Two other passengers were seriously injured. The coroner found these 'deaths in custody' as Norman was …

alcohol
VICcommunity2026-02-19

Finding into death of Kathleen Smith

53y · Female·Unascertained (presumed drowned)

Kathleen Smith, a 53-year-old podiatrist, disappeared on 15 July 2024 and is presumed to have drowned at Sorrento Back Beach. She was experiencing severe anxiety about upcoming foot surgery due to severe flatfoot deformi…

general practiceorthopaedic surgerycommunicationdelaysertraline
QLD2008-12-24

Trcka, Peter Joseph

54y · Male·Drowning after falling overboard from the Shanendale at Otter Reef

Peter Trcka, an experienced 54-year-old fisherman with an artificial leg and history of alcohol-related seizures, disappeared from a trawler anchored at Otter Reef on 1 March 2006. He was last seen at 4:30am appearing we…

emergency medicineneurologysystemdelay
VICaged care2019-07-31

Finding into death of Hong Tay

63y · Male·Sepsis in a man with complicated peripheral vascular disease

Hong Tay, a 63-year-old man with extensive peripheral vascular disease, diabetes, and prior amputations, died from sepsis in an aged care facility following a cervical spine fracture sustained in a fall. Aft…

geriatric medicinepalliative carecommunicationsystemfentanyl
NSWcommunity2020-01-24

Into the death of Thomas Redman

18y · Male·Incised wound to right axilla with complete transection of basilic vein, brachia…

Thomas Redman, aged 18, sustained a catastrophic laceration to his right axilla involving complete transection of major arteries and veins after putting his arm through a glass window at a rural property near Gloucester,…

emergency medicinetrauma surgerycommunicationsystemoxygen
WAhospital2016-05-18

Inquest into the Death of Janice May SAULYS

69y · Female·multi-organ failure due to sepsis of unknown origin

A 69-year-old woman with diabetes, cardiac disease, and vulnerable kidneys died from multi-organ failure due to sepsis of unknown origin. She presented to a rural hospital on 28 June 2012 with vomiting, dehydration, and …

emergency medicinegeneral practicesystemdelay
QLDhospital2018-08-20

RD - Non-inquest findings

64y · Male·Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia…

RD, a 64-year-old man with diabetes, amputation, and COPD, presented to a private hospital emergency department with suspected sepsis (vomiting, diarrho…

emergency medicineintensive carediagnosticmedicationintravenous normal saline
SAaged care2011-03-18

Coroner's Finding: HEATH Dawn Patricia

78y · Female·Severe burns sustained while smoking

A 78-year-old woman with dementia and significant manual dexterity deficits suffered fatal burns while smoking unsupervised in an aged care facility. Despite documented cognitive impairment and physical limitations preve…

systemcommunication
NSWhome2025-04-16

Inquest into the death of Colin Neil Amatto

40y · Male·septic complications from injuries received from multiple dog bites sustained on…

Colin Amatto, a 40-year-old Yuin man, died from septic complications following a devastating dog attack with over 80 bite wounds. Critical clinical lesson: the same dog (Boof, a Staffordshire Bull Terrier) had attacked a…

systemcommunication

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