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WAaged care

Inquest into the Death of Nola Inez DANIEL

83y · Female·Complications following fracture and surgical repair of the left hip in an elder…

Mrs Nola Inez Daniel, an 83-year-old with chronic lung disease, osteoporosis, and cardiac disease, was admitted to Regis Forrest Gardens for respite care on 24 December 2009. She sustained three falls on Christmas Day, w…

orthopaedic surgeryemergency medicinediagnosticcommunicationfentanyl
WAcommunity

Inquest into the Death of Keannita SAMSON

13y · Female·Chest and Head Injuries sustained in motor vehicle crash

A 13-year-old Aboriginal girl was a passenger in a stolen vehicle that was pursued by Western Australian police. The vehicle driver, also aged 13 and inexperienced, lost control during the pursuit, causing the vehicle to…

system
VIChome

Finding into death of E H

51y · Male·Complications of chronic ethanol use

EH was a 51-year-old man with chronic alcohol dependence, liver cirrhosis, and recent hip fracture complications who died at home on 1 November 2022 whilst waiting for an ambulance. He had self-discharged from St Vincent…

emergency medicineorthopaedic surgerysystemdelayalcohol
VIChome

Finding into death of Veeda

35y · Unknown·effects of fire

A 35-year-old died in a house fire on 26 November 2022 after inhaling smoke and toxic fire products. The fire originated in an upstairs bedroom, likely from an electrical device (vape or iPad) or smouldering cigarette. S…

systemalcohol
VICmental health

Finding into death of GM

52y · Male·Unascertained

GM, a 52-year-old man with bipolar affective disorder, died of unascertained causes after absconding from a mental health inpatient unit on 2 December 2015. He was admitted voluntarily for management of a suspected manic…

psychiatryemergency medicinesystemcommunicationpholcodine
VIC

Finding into death of Ze Cheng (Tony) Guan

Male·drowning

Tony Guan died by drowning at Ascot Vale Leisure Centre in 2014. The coronal inquiry identified that three staff members were present but failed to notice the incident, highlighting systemic failures in pool supervision.…

systemcommunication
VICcommunity

Finding into death of Alfred Norman Avage

79y · Male·head injuries sustained in a fall from a bicycle

A 79-year-old man died from head injuries sustained in a bicycle fall on a rural road. While riding at approximately 40 km/h on a descent, he swerved to avoid mud and debris on the road surface, struck another cyclist's …

neurosurgeryemergency medicinecommunicationsystem
VIChome

Finding into death of Ross Malcolm Campbell

40y · Male·neck compression consequent upon hanging

Ross Campbell, a 40-year-old man with a history of family violence perpetration, alcohol abuse, and undiagnosed mental illness, died by hanging. He had attended a Men's Behavioural Change Program in 2011 following a fami…

general practicepsychiatrycommunicationsystemalcohol
VIChospital

Finding into death of Sydney Hugh Kennedy

66y · Male·Complications of chronic lithium therapy

Sydney Kennedy, a 66-year-old man with intellectual disability and bipolar affective disorder, died from complications of chronic lithium therapy. He had been on lithium for years with annual psychiatric review, but ther…

psychiatrygeneral practicediagnosticcommunicationlithium
VIC

Finding into death of Kaye D Ward

60y · Female·Consistent with drowning

Kaye Ward, 60, drowned in Belfast Bay, Port Fairy after her fishing boat's motor failed to start due to corroded battery cable. With an undersized anchor that dragged ineffectively, the boat drifted into breaking waves a…

system
VICcommunity

Finding into death of Elaine O'Driscoll

28y · Female·Motor vehicle accident related chest injuries

Elaine O'Driscoll, a 28-year-old Irish working holiday maker, died from chest injuries sustained in a motor vehicle rollover on a rural road near Swan Hill, Victoria. The vehicle she was travelling in collided with a B-d…

system
VICcommunity

Finding into death of Jacob Anton Van Berlo

19y · Male·Hanging (self-inflicted)

Jacob Van Berlo, a 19-year-old male, died by hanging following a suicide. He had a history of depression treated with sertraline and an uncontrolled gambling addiction. On the day of death, after receiving his weekly pay…

general practicepsychologycommunicationsystemsertraline
VIChome

Finding into death of Jarrad John Ford

24y · Male·Aspiration pneumonia secondary to drug abuse and overdose of multiple drugs

A 24-year-old man with schizophrenia died from aspiration pneumonia following overdose of multiple drugs including diazepam, tramadol, morphine, and others. The day before death, he took excess diazepam to manage auditor…

psychiatryemergency medicinediagnosticsystemdiazepam
QLDhospital

Death of a Baby - Non-inquest findings

0y · Female·Subdural and subarachnoid haemorrhages due to late onset vitamin K deficiency bl…

A 33-day-old exclusively breastfed baby died from subdural and subarachnoid haemorrhages caused by late-onset vitamin K deficiency bleeding (VKDB). The parents, exercising informed choice based on spiritual beliefs, decl…

neonatologypaediatricsdiagnosticphytomenadione
QLDhome

Naidu, Alvin

15y · Male·Hypoxic ischaemic brain injury, due to hanging

A 15-year-old boy died from hypoxic-ischaemic brain injury following a hanging attempt on 10 November 2004. The death occurred hours after his parents were informed by the school that he had been absent for seven consecu…

systemcommunicationvibra-tabs
NTcommunity

Inquest into the death of Road Death 25 of 2024

42y · Male·Multiple blunt force injuries from motor vehicle collision (pedestrian), with ac…

A 42-year-old Aboriginal man died after being struck by a vehicle while lying intoxicated on a roadway at night in Coconut Grove, an identified alcohol-related crash hotspot. With a blood alcohol level of 0.22%, he was s…

systemalcohol
NT

Inquest into the death of Road Deaths 16 and 17 of 2024

Combination of smoke inhalation and thermal injuries sustained in motor vehicle …

Two men died in a single-vehicle motor vehicle collision on the Arnhem Highway on 28 March 2024. The driver (30M) and front-seat passenger (27M) were killed when their Toyota HiAce van left the road at approximately 160 …

forensic medicineemergency medicinesystem
VICcommunity

Tylercassidypart2 554208

Male·Multiple gunshot wounds from police shooting

Tyler Cassidy, 18, died after police shot him multiple times when he advanced on them with two knives in a public park. The coroner found that while Tyler's actions were deliberate, they were not voluntary—he was overwhe…

psychiatrycommunicationsystemalcohol
VIChome

Finding into death of Nathan Carl Skewes

31y · Male·mixed drug toxicity

Nathan Carl Skewes, age 31, died on 10 June 2012 from mixed drug toxicity involving his deceased wife's powerful palliative medications (fentanyl, ketamine, hydromorphone, morphine, codeine, paracetamol, cannabinoids). H…

systemfentanyl
VICaged care

Finding into death of Ellen Plymin

85y · Female·Sepsis relating to an infected right shoulder wound (including MRSA)

Ellen Plymin, aged 85, sustained a fractured humerus in a fall and underwent surgical fixation at Western Hospital on 10 May 2007. She returned to Westgate Aged Care Facility post-operatively on 14 May. By 28 May, wound …

general practiceorthopaedic surgerydiagnosticdelayoxycodone

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