Coronial

562 results for intellectual_disability

NSWhospital2020-01-31

Inquest into the death of OS

5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …

A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…

plastic and reconstructive surgeryanaesthesiamedicationproceduralmorphine
SAhome2023-09-20

Coroner's Finding: Norman, Colin

66y · Male·unascertained (differential diagnosis: chronic alcoholism with alcohol withdrawa…

Colin Norman, a 66-year-old man with significant disability from traumatic brain injury, chronic alcoholism and liver cirrhosis, died at home after failing to receive essential disability support services over a weekend.…

geriatric medicinesystemcommunication
QLDhome2025-07-15

Inquest into the death of Daniel Thomas Wright

8y · Male·prematurity-associated lung and bowel disease

Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associate…

neonatologypaediatricsdiagnosticcommunication
WAcommunity2026-02-02

Inquest into the Death of Joshua Fredrik VAN MALSSEN

24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…

Joshua Fredrik Van Malssen, 24, with Sotos syndrome, dilated cardiomyopathy, asthma, and WHO class III obesity (BMI 40.6) died from cardiac arrest on 16 June 2023 after being restrained in prone position by PTA transit o…

communicationproceduralalcohol
NSWaged care2018-09-25

Inquest into the death of Melissa STANDEN

13y · Female·Hanging

Melissa Standen, a 13-year-old with profound physical and cognitive disabilities (mosaicism), died from hanging at Westmead Children's Hospital after falling from a hospital bed at Allowah respite facility. She became en…

paediatricsoccupational therapydiagnosticsystem
WAhospital2018-06-25

Inquest into the Death of LCTM

0y · Male·complications of head injury

A premature newborn died from severe head injuries inflicted deliberately by his teenage father in hospital on 15 February 2014. The father had a well-documented history of violence, substance abuse, criminality and had …

neonatologypaediatricscommunicationsystem
VIChospital2014-05-20

Finding into death of Angela Therese Thompson

51y · Female·Aspiration pneumonia in a woman with Down syndrome and Alzheimer's dementia

Angela Thompson, a 51-year-old woman with Down syndrome and early-onset Alzheimer's dementia, died from aspiration pneumonia following a shoulder fracture. She was in DHS supported residential care when she suffered freq…

general practicepsychiatrysystemcommunicationescitalopram
VIChome2025-07-30

Finding into death of William Charles Heddergott

50y · Male·plastic bag asphyxia in the setting of ethanol intoxication and blunt force head…

William Heddergott, 50, died from asphyxiation with head injuries while intoxicated, in circumstances suggesting his mother Erica (who pleaded guilty to murder) perpetrated fatal family violence. Clinical lessons include…

psychiatrypsychologycommunicationsystemalcohol
WA2025-12-08

Inquest into the Death of Ashley James BROPHO

Male·Neck injury in a man with atherosclerotic heart disease

Ashley James Bropho, a vulnerable remand prisoner with intellectual impairment, schizophrenia, diabetes, previous myocardial infarction with stent, and atherosclerotic heart disease, was killed on 9 March 2023 at Hakea P…

correctional healthsystem
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…

Andrew William Barr, a 54-year-old man with Down syndrome and Alzheimer's dementia, died from complications of pelvic and spinal fractures sustained in a fall. Following his mother's death in January 2021 and his Februar…

orthopaedic surgerypalliative carecommunicationsystemanti-epileptic medication
TASmental health2017-11-17

Coroner's Finding: Smith, Molly Jessie

75y · Female·pyelonephritis and pneumonia

Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …

psychiatrygeneral practicediagnosticdelaycefalexin
VIChospital2025-10-17

Finding into death of Rachel Frances Piskun

42y · Female·Pneumonia, underlying severe cerebral palsy

Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…

emergency medicinegeneral medicinediagnosticmedicationmorphine
NSW2025-05-02

Inquest into the death of Emmett Brown

25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…

Emmett Brown, a 25-year-old First Nations man, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvida…

correctional healthaddiction medicinediagnosticsystemmethadone
QLDhospital2023-02-13

Hunter- Non-inquest findings

8y · Male·ischaemic bowel due to strangulated small bowel obstruction secondary to congeni…

An eight-year-old boy with autism spectrum disorder (level 1) died from ischaemic bowel due to strangulated small bowel obstruction from a rare congenital band adhesion. He presented to a regional hospital with abdominal…

surgerypaediatricsdiagnosticcommunicationondansetron
WA2025-11-28

Inquest into the Death of Cleveland Keith DODD

16y · Male·complications of ligature compression of the neck (hanging)

A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…

psychiatrypsychologyproceduralcommunication
QLD2025-10-01

Inquest into the death of Duke Allan Wayne Schafer

36y · Male·Ligature strangulation

Duke Schafer, 36-year-old prisoner, was murdered by fellow inmate Carl Bloomfield in May 2020 at Woodford Correctional Centre. Bloomfield strangled Schafer in an unsupervised laundry area during a period when officers we…

psychiatrypsychologysystemcommunicationbuprenorphine
WAhospital2022-03-28

Inquest into the Death of Morgan John EDWARDS

31y · Male·Complications in association with intestinal volvulus

31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…

emergency medicinegastroenterologydiagnosticcommunication
NSW2024-06-20

Inquest into the death of Michael Baker

44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…

Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…

general practicepsychiatrydiagnosticcommunicationmethadone
SA2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes including neck compression due to hanging (Ward, Ryan, Cooper) a…

This inquest into four deaths on the Anangu Pitjantjatjara Lands involved multiple causes including hanging (three cases) and exposure with complications. Kunmanara Ward died by hanging while intoxicated with petrol; Kun…

psychiatryemergency medicinecommunicationsystempetrol
NSW2022-07-06

Inquest into the death of Kevin BUGMY

57y · Male·Severe coronary artery disease. It is likely that Kevin's use of inhalants in cu…

Kevin Bugmy, a 57-year-old Aboriginal man, died of severe coronary artery disease while in custody at Cessnock Correctional Centre. The coroner found the care received for his chronic inhalant use disorder was grossly in…

cardiologygeneral practicediagnosticcommunicationacetone

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