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NSWhospital2026-01-13

Inquest into the death of Paul Harris

43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…

Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …

general practiceemergency medicinediagnosticcommunicationceftriaxone
NThospital2026-01-09

Inquest into the death of C Guyula

49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …

A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical fa…

anaesthesiasurgeryproceduralmedicationfentanyl
WA2026-01-08

Inquest into the Death of Lewis Walter WARD

Male·out-of-hospital cardiac arrest due to atherosclerotic cardiovascular disease and…

Lewis Walter Ward, a Ngarinyin man in his early thirties, died from out-of-hospital cardiac arrest while playing sport at West Kimberley Regional Prison. He had Type 2 diabetes, hypertension, dyslipidaemia, and was a smo…

cardiologyemergency medicinediagnosticsystem
WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…

psychiatryintensive caresystemdelayaripiprazole depot
NThospital2025-12-19

Inquest into the death of T. Ptjara and T. Ptjara

Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…

Two Aboriginal brothers with chronic alcohol use disorder and cognitive impairment died in July and September 2023 in Alice Springs Hospital. Both had adult guardianship orders, NDIS packages, and aged care assessments r…

emergency medicineintensive carecommunicationsystem
NSWhospital2025-12-08

Inquest into the death of Katrina McGrady

43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm

Trina McGrady, a 43-year-old Goomeroi woman, died from subarachnoid haemorrhage due to a ruptured berry aneurysm on 15 September 2020. She had been admitted to John Hunter Hospital following incidental discovery of two l…

neurosurgeryradiologycommunicationdiagnosticaspirin
VIChospital2025-12-01

Finding into death of Larelle Sheridan Dean

51y · Female·Multiorgan failure in the setting of WHO Class III obesity, chronic excessive al…

A 51-year-old woman with WHO Class III obesity, chronic alcohol consumption, and anaemia died of multiorgan failure following admission with community-acquired pneumonia and respiratory failure. She presented with abdomi…

general medicineemergency medicinehydromorphone
TAShospital2025-11-28

Coroner's Finding: Clark, Dennis

83y · Male·Sepsis due to staphylococcus aureus bacteraemia following infection of a left an…

An 83-year-old man with heart and kidney failure died from sepsis caused by MSSA bacteraemia following infection at a peripheral intravenous catheter (PIVC) insertion site. Ambulance paramedics inserted the PIVC 56 hours…

emergency medicinesurgeryproceduralsystem
VIChospital2025-11-28

Finding into death of Carol Denise Jackson

75y · Female·Pneumonia

Carol Denise Jackson, a 75-year-old woman with cerebral palsy, intellectual disability, and dysphagia residing in specialist disability accommodation, died of pneumonia following a short hospital admission. She presented…

emergency medicinegeneral medicine
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
VIChome2025-11-18

Finding into death of JZA

65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …

A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…

geriatric medicineinfectious diseasessystemcommunicationpholcodine
NSWhospital2025-11-17

Inquest into the death of Brooke Tiddy

32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…

A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…

bariatric surgeryanaesthesiadiagnosticcommunicationsevoflurane
SAhospital2025-11-14

Coroner's Finding: Wallace, Peter John

67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …

Peter John Wallace, aged 67, died in custody at Lyell McEwin Hospital from hypoxic respiratory failure complicating pneumonia, pulmonary embolism, and advanced hepatocellular carcinoma. He had been imprisoned at Yatala L…

hepatologyoncologyenoxaparin
SAhospital2025-11-14

Coroner's Finding: Menzies, Jason Douglas

33y · Male·Marburg variant of multiple sclerosis

Jason Menzies, aged 33, died in custody from Marburg variant multiple sclerosis after rapid neurological deterioration. He initially presented with urinary retention on 1 December 2022, which was appropriately investigat…

emergency medicinegeneral medicineamitriptyline
SAhome2025-11-13

Coroner's Finding: Platten, Garry David

72y · Male·hypoxic brain injury due to cardiac arrest due to compression of the neck due to…

A 72-year-old man on home detention bail for alleged sexual offending died by hanging after experiencing cumulative stressors. Key events included arrest, placement on home detention, and subsequent media coverage of cha…

emergency medicineintensive care
VIC2025-11-10

Finding into death of Andrew Phillip John Kursinskis

57y · Male·Complications following food aspiration in a man with multiple co-morbidities

Andrew Kursinskis, a 57-year-old man with intellectual disability, dysphagia, autism, epilepsy and pica, died from complications following aspiration of chicken schnitzel while living in supported disability accommodatio…

speech pathologyemergency medicinesystemcommunicationlevetiracetam
SAhospital2025-11-05

Coroner's Finding: Jackson, Dennis Charles

67y · Male·Type 2 respiratory failure due to pneumonia

Dennis Jackson, a 67-year-old from Broken Hill, underwent left upper lobe lobectomy based on a falsely positive lung biopsy contaminated with squamous cell carcinoma tissue from another patient during processing at SA Pa…

cardiothoracic surgerypathologydiagnosticsystem
VIC2025-10-29

Finding into death of David James Klingberg

55y · Male·Complications of traumatic head injury sustained in a workplace incident (pallia…

David Klingberg, a 55-year-old experienced pile testing engineer, died from traumatic head injury sustained when an auxiliary line hook on a piling rig struck him in the face at a construction site. The hook became jamme…

emergency medicineintensive caresystemmorphine
VIC2025-10-28

Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for the management of sep…

Christopher McIntosh, a 54-year-old man with type 2 diabetes, died from respiratory failure secondary to sepsis originating from an infected foot ulcer while incarcerated at Hopkins Correctional Centre. The coroner found…

correctional healthgeneral medicinecommunicationsystem
VIChospital2025-10-28

Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …

Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarce…

infectious diseasesvascular surgerydiagnosticsystemantibiotics

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