Coronial
VIC2021-02-24

Finding into death of Mark Capovilla

39y · Male·Choking on a food bolus

Mark Capovilla, a 39-year-old man with severe intellectual disability, epilepsy, and dysphagia, died from choking on food at his day program. He had a documented choking risk but lacked a current mealtime support plan at…

general practiceforensic medicinecommunicationsystem
VIChospital2024-08-07

Finding into death of Georgios Stamkos

68y · Male·Complications of a witnessed airway obstruction from food bolus in a man with dy…

A 68-year-old man with dysphagia and bipolar disorder died from airway obstruction and aspiration pneumonia after choking on a sandwich brought by his wife during a supervised hospital meal. He had been admitted with wor…

psychiatryspeech pathologyrisperidone
NSWmental health2019-06-04

Inquest into the death of Andrea Sewell

46y · Female·hypoxic ischaemic brain injury as a result of cardiac arrest following a choking…

Andrea Sewell, a 46-year-old woman with Osmotic Demyelination Syndrome (ODS) and acute psychiatric illness, died from hypoxic brain injury following a choking episode during a meal in a psychiatric intensive care unit (P…

psychiatryneurologyantipsychotic medications
QLDhospital2005-10-06

Fernandez, Adam Anthony

33y · Male·Aspiration due to alcoholic intoxication; coronary atherosclerosis contributed

Adam Anthony Fernandez, aged 33, died from aspiration of food contents while acutely intoxicated (blood alcohol 0.276%) following police attendance at his home on 4 December 2001. After police used capsicum spray to safe…

emergency medicineanaesthesiasedatives
NSWaged care2021-09-22

Inquest into the death of Vakabauta LEONE

47y · Female·complications of rapidly progressing motor neurone disease

A 47-year-old woman with motor neurone disease died from respiratory complications while in immigration detention, residing in aged care. She collapsed at 1:00am with respiratory distress. Nursing staff did not attempt C…

palliative careemergency medicinecommunicationdelay
VICaged care2014

Finding into death of Marjorie Hall

75y · Female·Aspiration of food in a woman with dementia

A 75-year-old woman with advanced dementia died from aspiration of food in an aged care facility. Despite being on a thickened diet and requiring full supervision due to documented swallowing difficulties and a tendency …

geriatric medicinespeech pathologysystemcommunicationrisperidone
NThospital2017-08-10

Inquest into the death of Ruby Blitner

7y · Female·respiratory failure from severe scoliosis due to Murray Valley encephalitis

… had been established after discussion with family in October 2015, restricting interventions to oxygen, suctioning, antibiotics and physiotherapy without intubation or mechanical ventilation. On admission with aspiratio…

paediatricsinfectious diseases
VIChospital2021-11-18

Finding into death of Pippa May Griffiths

<1y · Female·Neonatal death in the setting of meconium aspiration

A term neonate died from meconium aspiration three hours after spontaneous labour onset. The mother had presented to hospital the previous day with decreased foetal movements and was discharged without comprehensive asse…

obstetricsmidwiferycommunicationdiagnosticbenzyl penicillin
QLDhome2008-12-22

Plint, Hannah Isabella Alyson

2y · Female·Drowning in an above-ground swimming pool

Hannah Plint, a 2½-year-old, died from drowning after accessing an above-ground pool by dragging a chair to the gate and opening it unsupervised. Her mother was inside with a younger sibling. The pool fence and gate sepa…

emergency medicinepaediatricssystemdelay
QLDcommunity2026-02-13

Inquest into the passing of Steven Lee Nixon-McKellar

27y · Male·Sudden cardiac arrest in the context of physical and psychological exertion duri…

Steven Nixon-McKellar, a 27-year-old First Nations man, died following a physical altercation with Queensland Police officers attempting to arrest him on 7 October 2021. He suffered cardiac arrest during restraint, with …

emergency medicineforensic medicinemethamphetamine
WAmental health2020-08-06

Inquest into the Death of Stephen Michael KELL

35y · Male·acute vomit aspiration in a man with acute large intestine obstruction (severe m…

Stephen Michael Kell, a 35-year-old man with treatment-resistant schizophrenia, died at Graylands Hospital from acute vomit aspiration in the setting of acute large bowel obstruction and clozapine-induced gastrointestina…

psychiatrygastroenterologysystemdelayclozapine
SAcommunity2023-05-26

Coroner's Finding: Latouche Mazzei, Lucas

5y · Male·acute upper airway obstruction from nectarine stone

Lucas Mazzei, aged 5 years, died on 27 March 2017 from acute upper airway obstruction caused by an uncut nectarine stone. While attending school, he was separated from his class during a science lesson and left watching …

emergency medicinepaediatricscommunicationsystemlamotrigine
NSWaged care2014-05-23

Inquest into the death of Beryl Joyce WATSON

70y · Female·Aspiration pneumonia, associated with Huntington's disease

Beryl Watson, a severely disabled 70-year-old with advanced Huntington's disease and dementia, died of aspiration pneumonia following a three-week respite stay at a BUPA aged care facility. Critical failures included: om…

geriatric medicinegeneral practicemedicationcommunicationclonazepam
WAhospital2025-04-17

Inquest into the Deaths of HC and Child HR

Unknown·terminal palliative care in a girl with a clinical diagnosis of aspiration pneum…

A 12-year-old girl with severe cerebral palsy (quadriplegia) died from aspiration pneumonia whilst in state care following removal from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence,…

paediatricspalliative care
VIChome2021-08-04

Finding into death of NB

1y · Male·Global cerebral ischaemia in an infant with upper airway obstruction

NB, a 14-month-old with a tracheostomy requiring overnight nursing support in foster care, suffered a cardiac arrest on 17 December 2016 that resulted in severe hypoxic brain injury and death. The overnight nurse (Ms Jar…

respiratory medicineintensive carediagnosticcommunication
NSWhospital2022-12-21

Inquest into death of Andrea LESTER

49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…

Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfu…

neurosurgeryintensive carediagnosticcommunicationtramadol

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