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NSW2025-10-22

Inquest into the Death of Frank Dwayne COLEMAN

43y · Male·methadone toxicity

Frank Coleman, a 43-year-old First Nations man, died of methadone toxicity after being supplied diverted methadone by another inmate while imprisoned at Long Bay Correctional Complex. Mr Coleman had repeatedly requested …

addiction medicinepsychiatrydiagnosticsystemmethadone
SAcommunity2025-10-20

Coroner's Finding: Kennedy, John Douglas

65y · Male·Ischaemic heart disease on a background of hypertension

John Kennedy, 65, died from ischaemic heart disease with hypertension on 16 April 2020 after a 24-minute delay in ambulance dispatch. He called triple zero at 00:19 with severe chest pain and difficulty breathing (Priori…

emergency medicinecardiologycommunicationsystematenolol
VIChospital2025-10-09

Finding into death of Stephen Ross Stronach

57y · Male·Pneumonia with contributing factors of epilepsy and congestive cardiac failure d…

Stephen Ross Stronach, a 57-year-old man with intellectual disability living in specialist disability accommodation, died of pneumonia with contributing factors of epilepsy and congestive cardiac failure secondary to rep…

general practiceemergency medicineantibiotics
VIC2025-10-08

Finding into death of Richard Paul Atkins

65y · Male·Ischaemic heart disease in a man with epilepsy

Richard Paul Atkins, a 65-year-old man with intellectual disability and epilepsy living in specialist disability accommodation, died from ischaemic heart disease. Post-mortem examination revealed moderate to severe tripl…

cardiologyneurologycarbamazepine
VIC2025-10-07

Finding into death of Anthony George Creaton

55y · Male·Acute myocardial infarction secondary to coronary artery thrombosis due to coron…

Anthony Creaton, 55, died of acute myocardial infarction due to coronary artery thrombosis and atherosclerosis in prison custody. He presented with chest pain on 13 November 2022 (twice) and again on 14 November, but nur…

cardiologygeneral practicediagnosticcommunicationgliclazide
VIC2025-09-23

Finding into death of Frederick William Boyle

74y · Male·Congestive heart failure on a background of recent influenza A infection, end st…

Frederick William Boyle, aged 74, died of congestive heart failure in the setting of influenza A infection, end-stage dementia, and Parkinson's disease while in Port Phillip Prison. He had been transferred from St Vincen…

geriatric medicinepalliative caresystem
VICaged care2025-09-10

Finding into death of IWT

77y · Female·Complications of malnutrition in a woman with paranoid delusions

A 77-year-old woman with complex medical and psychiatric history died from complications of malnutrition while an inpatient with paranoid delusions and delirium. She was admitted following falls and required compulsory t…

psychiatrygeriatric medicineolanzapine
NSWprison2025-09-05

Inquest into the death of Dushyanthan Visvanathan

55y · Male·Complications of alcohol use disorder

Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequa…

addiction medicineemergency medicinecommunicationdocumentationdiazepam
NSW2025-09-03

Inquest into the death of Daniel Leehy

47y · Male·ischaemic heart disease with seizure disorder and schizophrenia being other sign…

Daniel Leehy, a 47-year-old man in custody, died from ischaemic heart disease with significant coronary artery narrowing (60-80%) identified at autopsy. He had a 42-year history of epilepsy and schizophrenia with frequen…

forensic medicinepsychiatrysodium valproate
NSWhospital2025-08-22

Inquest into the death of Frank Valentine

83y · Male·Congestive cardiac failure due to ischaemic and valvular heart disease, with her…

Frank Valentine, an 83-year-old man, died from congestive cardiac failure due to ischaemic and valvular heart disease, with hereditary haemorrhagic telangiectasia (HHT) and anaemia as contributory conditions. He was serv…

cardiologygastroenterologywarfarin
VIC2025-08-21

Finding into death of Catherine Mary Stephen

63y · Female·Natural causes unascertained; probable aspiration pneumonia with large pericardi…

Catherine Stephen, a 63-year-old woman with cerebral palsy, spastic quadriplegia, epilepsy, and kyphoscoliosis, died from natural causes unascertained at a hospice following palliative care. She had been admitted to hosp…

palliative caregeneral medicine
VIC2025-08-18

Finding into death of Wilhelm Bruno Mueller

69y · Male·Ischaemic and hypertensive heart disease

Wilhelm Mueller, a 69-year-old prisoner at Middleton Prison, died suddenly from ischaemic and hypertensive heart disease. Autopsy revealed critical coronary artery stenosis (>75%) with cardiac hypertrophy and remote myoc…

cardiologygeneral practicegliclazide
VIChospital2025-08-15

Finding into death of Person E

70y · Male·organising diffuse alveolar damage in the setting of hypertensive heart disease,…

A 70-year-old man died in prison custody from organising diffuse alveolar damage in the setting of pre-existing hypertensive heart disease, right ventricular hypertrophy, coronary artery atherosclerosis, and COPD. He pre…

respiratory medicineintensive care
QLDhospital2025-08-11

Inquest into the death of John Reginald Wright

79y · Male·Complications of peripheral vascular disease with Type 2 Diabetes Mellitus, atri…

John Reginald Wright, a 79-year-old remand prisoner, died from complications of peripheral vascular disease with diabetes, atrial fibrillation, cardiomyopathy and delirium. He was transferred to Princess Alexandra Hospit…

vascular surgerygeneral medicineglicazide
VIChospital2025-08-11

Finding into death of JBL

73y · Male·Multiorgan dysfunction in the setting of severe heart failure in a man with mult…

A 73-year-old man with Fragile X syndrome, intellectual disability, Barrett's oesophagus, and epilepsy died from multiorgan dysfunction in severe heart failure. He had experienced progressive health decline over months, …

geriatric medicinecardiology
NSWcustody2025-08-07

Inquest into the death of Lathan Brown

28y · Male·Cardiac arrhythmia

Lathan Brown, a 28-year-old Aboriginal man, died of cardiac arrhythmia while in custody at Wellington Correctional Centre on 6 January 2024. He suffered sudden cardiac arrest in his cell; emergency response was appropria…

cardiologyemergency medicinecommunicationsystem
VIC2025-08-06

Finding into death of Brian Matthew McDonald

69y · Male·Haemopericardium secondary to ischaemic heart disease

Brian Matthew McDonald, a 69-year-old man with autism, intellectual disability, and epilepsy living in specialist disability accommodation, died from haemopericardium secondary to ischaemic heart disease. He collapsed in…

cardiologyforensic medicinelevetiracetam
SAhospitalPodcast2025-07-31

Coroner's Finding: Panella, Anna Vincenza and Skeffington, Bernard Anthony and Jessett, Graham Henry

Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…

Three South Australians died following extended waits on ambulance ramps outside metropolitan hospitals. Anna Panella (76) died from pulmonary thromboembolism; Bernard Skeffington (89) died from aspiration pneumonia afte…

emergency medicinecardiologycommunicationsystem
NSWhome2025-07-30

Inquest into the death of Hilary Gordon-Squire

65y · Male·Pneumonia, due to chronic lung disease with atherosclerotic cardiovascular disea…

A 65-year-old man with severe chronic lung disease, COPD, and coronary artery disease died at home. Evidence suggests he deliberately ingested benzodiazepines and possibly other substances in a self-harm attempt. However…

forensic medicinegeneral practicesystemdelaybenzodiazepines
VIChome2025-07-28

Finding into death of Heather Ida Simone Calgaret

30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…

Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …

general practiceaddiction medicinemedicationdiagnosticbuprenorphine

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