Coronial
WA2015-03-17

Inquest into the Death of Thomas Francis LEVINGE

73y · Male·Unknown (possibly impact with water, drowning, injury, exhaustion, dehydration, …

A 73-year-old man with recent cognitive decline jumped from a cruise ship in Western Australia, resulting in death. Clinical lessons include recognising that cognitive impairment and depression may manifest as behavioura…

diagnostictemazepam
WAcommunity2020-06-03

Inquest into the Suspected Death of Anthony JOHNSTONE

33y · Male·Exposure to the elements whilst in a mentally unstable state; manner of death Op…

…ated. The coroner established beyond reasonable doubt that he died by end 1996, likely from exposure and exhaustion while evading contact due to his mental disturbance. No remains were ever found. The case highlights the…

alcohol
VICcommunityNew2026-07-01

Finding into death of Earl Allen Blessing Jr

56y · Male·Drowning in the setting of scuba diving

Earl Allen Blessing Jr., 56, died while scuba diving alone in Port Phillip Bay near Rye Pier on 3 February 2024. The coroner found he drowned after running out of air during his dive, having either entered the water with…

proceduralsystem
QLDhospital2011-06-29

Heidrich, Bela

0y · Female·Mechanical asphyxia due to or as a consequence of overlaying while bed-sharing d…

Bela Heidrich, a newborn, died from mechanical asphyxia due to overlaying while bed-sharing with her mother during breastfeeding in hospital. The mother, Zelia, was exhausted after labour and fell asleep while breastfeed…

midwiferyobstetricscommunicationsupervisionpethidine
VIChome2015-12-10

Finding into death of Stuart Rattle

53y · Male·Compression of the neck

Stuart Rattle, a 53-year-old man, died from compression of the neck inflicted by his partner of 15 years during a domestic dispute. The death resulted from an escalation of longstanding family violence involving emotiona…

VIChome2017-04-13

Finding into death of Baby Isabella Rose

0y · Female·Sudden Infant Death Syndrome (Category 2)

A 4-week-old infant died from Sudden Infant Death Syndrome Category 2 in an unsafe co-sleeping environment. She was placed on a mattress on the lounge room floor between her parents, who were also sleeping on the mattres…

paediatricsneonatologycannabis
NSWcommunity2018-03-02

Inquest into the disappearance and suspected death of Jordan Morris

22y · Male·Unknown - likely drowning in Boundary Creek/Nepean River but unable to be determ…

Jordan Morris, aged 22, disappeared on 24 April 2015 following a police pursuit of a stolen vehicle in Penrith, NSW. After the vehicle stopped, Jordan fled into bushland adjacent to Boundary Creek. Police searched extens…

systemdelay
QLDhospital2007-11-06

Huber, Arisa

1y · Female·sudden unexpected death in infancy due to hypoxic episode while co-bedding with …

… lessons include: (1) the mother received no specific warning about risks of bed-sharing despite extreme exhaustion after labour and birth; (2) the required 15-30 minute observation intervals while mother breastfeeding i…

neonatologyobstetricscommunicationsystem
VIC2017-10-31

Finding into death of Andrew John Harman

49y · Male·Complications of heatstroke; Hyperthermia

… cardiac arrest and died despite resuscitation. Clinical lessons include recognizing early signs of heat exhaustion in physically exerting individuals, ensuring adequate hydration is accessible, and considering cessation…

emergency medicineintensive caredelay
WAhomePodcast2016-04-11

Inquest into the Death of TPL (a child Subject to a Suppression Order)

0y · Unknown·bronchopneumonia and hypoxic brain injury following immersion (near-drowning)

A six-month-old infant died from bronchopneumonia and hypoxic brain injury following immersion in a shower. The child was placed unsupervised in a Bumbo seat in a running shower while the mother attended to other tasks f…

system
WA2022-02-09

Inquest into the Suspected Death of Pei Yao CHEN

41y · Male·Drowning in the Indian Ocean near B-7 Anchorage Point approximately 13 miles fro…

Pei Yao Chen, a 41-year-old Bosun, fell overboard from the cargo ship Cape Splendor while fishing from an accommodation ladder during a lunch break in October 2014. Despite wearing work clothes and no lifejacket (contrar…

system
VICcommunity2016-09-16

Finding into death of Paul Mervyn Gendre

61y · Male·drowning in a man with ischaemic heart disease

A 61-year-old man with ischaemic heart disease (70% stenosis of major coronary arteries) drowned while solo boating on Lake Dartmouth in winter conditions. He was not wearing a personal floatation device, had a blood alc…

forensic medicinegeneral practicesystem
WA2017-12-29

Inquest into the Death of Andrew Trevor HINDS and Nigel Paradine KITCHEN

50y · Male·Drowning following capsizing and disintegration of recreational fishing vessel i…

Two experienced recreational fishermen, Nigel Kitchen (50) and Andrew Hinds (57), departed Coral Bay on 29 May 2016 in a 8.2-metre vessel in deteriorating weather conditions (predicted swell 2-4 metres). Despite warnings…

WAcommunity2022-08-18

Inquest into the Suspected Death of Nicholas PAVLIDIS

Male·Unknown - presumed deceased from exposure, heat exhaustion, or injury during unp…

Nicholas Pavlidis disappeared in October 2015 from Yanchep, Western Australia. He was last seen alive on 14 October 2015 by a friend. His vehicle was found abandoned in a pine plantation on 24 October 2015. Despite exten…

general practicepsychologysystemdelayfluoxetine
VIChospital2015-04-23

Finding into death of Craig Ronald McMillan

37y · Male·Unascertained (death in custody)

Craig McMillan, 37-year-old male with chronic schizophrenia, died of undetermined cause (death in custody) after being transported by police divisional van to hospital. Despite documented tachycardia from Risperidone, th…

psychiatryemergency medicinecommunicationsystemrisperidone
WAhospital2003-07

Inquest into the Death of Mark Andrew Burnside

45y · Male·Natural causes - cardiac arrest, most likely secondary to severe tardive dyskine…

Mark Andrew Burnside, a 45-year-old man with intellectual disability and chronic mental illness, died of natural causes on 7 November 2001 at Royal Perth Hospital. He had been prescribed thioridazine (Mellaril) for appro…

general practicepsychiatrythioridazine
QLD2021-08-20

Caramin, Olivier Max - Non-inquest findings

27y · Male·multiple organ failure due to or as a consequence of heat stroke

Olivier Caramin, a 27-year-old Belgian national on a working holiday visa, died from heat stroke while picking pumpkins on 31 October 2017 in Far North Queensland. He was just three days into farm work without proper acc…

occupational and environmental healthemergency medicinesystemdiagnostic
NT2001-10-16

Inquest into the death of Christopher Limerick

20y · Male·Unable to be determined. Death likely resulted from exposure following a fall wh…

Christopher Limerick, a 20-year-old Aboriginal man with alcohol dependency, was found dead at the bottom of Noble's Nob open-cut mine near Tennant Creek. Despite extensive investigation, the cause of death could not be d…

forensic medicineemergency medicinecommunicationsystem
VIChome2017

Finding into death of Harold George Nolan

73y · Male·Stab wound to the neck

Harold Nolan, 73, was fatally stabbed in the neck by his ex-wife Renee Nolan while asleep at home. Ms Nolan was his full-time carer following his 2013 stroke and was experiencing severe carer fatigue, mental health deter…

general practicepsychiatrycommunicationdelayantidepressants
SAcommunity2018-02-23

Finding into death of Alexander Sheng Wei Li

16y · Male·Heat related illness in an individual with enterovirus D68 infection

Alexander Li, a 16-year-old with underlying enterovirus D68 infection, died of heat-related illness during a school bushwalking expedition in remote South Australia in extremely hot conditions (temperatures reaching 39.1…

emergency medicineparamedicinesystemcommunication

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