Coronial

93 results for cognitive disability

VIChospital2025-04-30

Finding into death of Anthony Dzaja

44y · Male·Complications following seizure on a background of acquired epilepsy; acquired b…

…97 motor vehicle accident. He had progressively deteriorated over several years with worsening epilepsy, cognitive decline, and mobility loss, requiring increasing levels of care. In his final admission, Anthony develop…

neurologypalliative caremidazolam
VIChome2025-07-03

Finding into death of Stephanie Rebernik

69y · Female·Effects of fire

…ephanie Rebernik, aged 69, died in a house fire in 2023. She had an acquired brain injury from 1980 with cognitive decline, poor risk identification, and a documented five-year history of unsafe fire-lighting behaviours…

occupational therapypsychiatrysystemdelayoxazepam
VICcommunity2022-11-24

Finding into death of Durdica Serbec

65y · Female·Injuries Sustained in Motor Vehicle Collision (Pedestrian)

A 65-year-old woman with profound cognitive impairment was struck by a vehicle driven by a learner driver who was operating the motor vehicle withou…

VIChospital2026-01-13

Finding into death of Sushant Padhye

56y · Male·Recurrent aspiration pneumonia in a man with congenital disability and cognitive…

A 56-year-old man with congenital microcephaly, intellectual disability, dysphagia and recurrent aspiration pneumonia died from aspiration pneumonia whilst receiving palliative…

emergency medicinepalliative carecarbamazepine
VIChome2019-03-28

Finding into death of Vicki Jane Bennett

56y · Female·Pneumonia

A 56-year-old woman with intellectual disability died of pneumonia at her DHHS group home. She presented with vomiting and diarrhoea on 23 June, and a do…

general practiceforensic medicine
VIChospital2024-01-25

Finding into death of Wayne Thomas Jamieson

56y · Male·Aspiration pneumonia, complicated by myocardial infarction and right heart failu…

Wayne Thomas Jamieson, a 56-year-old man with profound intellectual disability and Osteogerma Dysblastica, died from aspiration pneumonia complicated by myocardial infarction and righ…

respiratory medicinecardiology
VIC2018-10-26

Finding into death of John Gorman Maltman

71y · Male·Coronary artery atherosclerosis

John Maltman, a 71-year-old man with intellectual disability and early Alzheimer's, died from coronary artery atherosclerosis after leaving residential care on 26 De…

VIChospital2019-08-30

Finding into death of Agostino Cutugno

57y · Male·Small bowel perforation complicating small bowel obstruction arising from intra-…

Agostino Cutugno, a 57-year-old prisoner with intellectual disability (IQ 55) and history of self-inflicted abdominal stab wounds, died from small bowel perforation complicat…

general surgeryintensive carecommunicationsystemproton pump inhibitors
VICaged care2022-07-06

Finding into death of Catherine Ann Collier

51y · Female·Aspiration in the setting of end stage down syndrome

…alus, and severe dysphagia, died from aspiration pneumonia following a choking episode while eating. The Disability Services Commissioner investigation identified critical gaps in her care: no current individualised meal…

neurologyspeech pathologysystemcommunicationsodium valproate
VIChospital2024-12-09

Finding into death of Peter A Keating

37y · Male·Pseudomonas pneumonia

Peter Keating, a 37-year-old man with cerebral palsy and intellectual disability living in supported accommodation, died from pseudomonas pneumonia following a month-long hospitalisatio…

respiratory medicineinfectious diseasesantibiotics
VIC2015-05-07

Finding into death of Louis Gerard Le Boeuf

24y · Male·unascertained

…, disappeared from the Sunbury Training Centre on 23 November 1977. He had severe epilepsy, intellectual disability, and required full support for daily living including assistance with walking. He was placed on a verand…

psychiatryneurologycommunicationsystem
TAShome2023-11-07

Coroner's Finding: Humphries, Leeanne Margaret

55y · Female·smoke inhalation from domestic fire caused by unextinguished cigarette

A 55-year-old woman with a prior stroke causing physical disability, intellectual disability, schizophrenia, epilepsy, diabetes and atrial fibrillation died from smoke inha…

psychiatryneurologytapentadol
VIChospital2010-05-20

Finding into death of Laurel Faith Howard

52y · Female·Aspiration pneumonia secondary to Alzheimer's disease

…own syndrome and Alzheimer's disease who died from aspiration pneumonia in hospital. She had progressive cognitive and functional decline, requiring high-level residential care and assistance with feeding in specific po…

geriatric medicinepalliative caremorphine
VIChospital2024-12-09

Finding into death of Robert Djurovich

58y · Male·Aspiration pneumonia

…pital on 1 November 2022 following an aspiration event. He had been a long-term resident of a Specialist Disability Accommodation facility and was an NDIS participant. His health had been declining for six years due to p…

respiratory medicineinfectious diseases
NSWcommunity2025-07-10

Inquest into the death of Nathan Markl

31y · Male·Drowning

…st-flowing creek while attempting to exit his vehicle. Key clinical lessons: vulnerable individuals with cognitive impairment, mental health conditions, and substance use require heightened safeguarding; the combination…

psychiatryaddiction medicinesystemdelaymethamphetamine
WAcommunity2018-05-31

Inquest into the Death of Charles TUDAWALI (aka Charlie Martin)

13y · Male·unascertained

Charles Tudawali, a 13-year-old Aboriginal boy with intellectual disability (mental age 7 years) and epilepsy requiring three-daily medication, went missing on 15 December 1976 whi…

VIChospital2026-02-16

Finding into death of Marcello Sardo

60y · Male·Aspiration pneumonitis in a man with Down Syndrome

…priate escalation of care, and recognition of aspiration risk in patients with dementia and intellectual disability. Early palliative involvement and clear documentation of goals of care were appropriately managed in thi…

geriatric medicinepalliative care
VIChospital2025-08-21

Finding into death of Andrew William Barr

54y · Male·Complications of pelvic and spinal fractures sustained in a fall in man with Dow…

…ghts critical systemic failures: absence of a formal medical treatment decision-maker (MTDM) despite his cognitive impairment, lack of advance care planning, delayed guardianship appointment, poor communication with his…

orthopaedic surgerypalliative carecommunicationsystemanti-epileptic medication
VIChospital2025-08-17

Finding into death of Stephen Feltscheer

61y · Male·aspiration pneumonia in a man with Down syndrome and early onset dementia

Stephen Feltscheer, a 61-year-old man with Down syndrome and early onset dementia living in Specialist Disability Accommodation, died from aspiration pneumonia. He was admitted to hospital on 25 July 2024 with a two-da…

palliative careinfectious diseasesmidazolam
VICaged care2020

Finding into death of Sharon Brown

54y · Female·COMPLICATIONS OF DEMENTIA

Sharon Brown, a 54-year-old ward of the state with dementia, intellectual disability, and epilepsy, died from complications of dementia including aspiration pneumonia. She was admitted to M…

general practicegeneral medicine

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