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VIChome2026-03-19

Finding into death of Aisha Natasha Khan

44y · Female·Mixed alcohol and drug toxicity (tapentadol, diazepam, mirtazapine, amitriptylin…

Aisha Natasha Khan, 44, died from mixed alcohol and drug toxicity following an intentional polypharmacy overdose with alcohol consumption. She had a history of depression, alcohol use disorder, chronic pain, and two prio…

psychiatryemergency medicinesystemdelaytapentadol
VIChome2026-03-19

Finding into death of Catherine Alison Lynch

41y · Female·Mixed drug toxicity (alprazolam, clonazepam, diazepam, methadone, metoclopramide…

Catherine Lynch, a 41-year-old nurse, died from mixed drug toxicity in July 2022 in circumstances consistent with suicide. She was experiencing severe family violence, including coercive control, threats, stalking and em…

psychiatrypsychologycommunicationsystemalprazolam
VIC2026-03-19

Finding into death of Rhiannon Charlotte Drake

30y · Female·Head injuries sustained in a motor vehicle incident (passenger)

A 30-year-old female passenger died from head injuries sustained in a multi-vehicle collision on the Princes Highway when a truck failed to stop in time. The collision resulted from a 'looming collision'—where the truck …

systemdelay
NSWhospital2026-03-17

Inquest into the death of Gia Lam

32y · Female·Sepsis due to pyelonephritis of the right kidney due to acute and chronic cystit…

A 32-year-old Vietnamese-speaking woman died from sepsis due to pyelonephritis following premature discharge from hospital onto a midwifery support program. Multiple missed diagnostic opportunities occurred: difficulty p…

obstetricsmidwiferydiagnosticcommunication
NSWhospital2026-03-17

Inquest into the death of Serena Lee

1y · Female·Obstructive sleep apnoea occurring in the context of significant, unrecognised h…

Serena Lee, born 31 October 2021, died at 2 months from obstructive sleep apnoea in the context of severe, unrecognised hypoglycaemia associated with intrauterine growth restriction (IUGR). She was discharged from Campbe…

neonatologymidwiferydiagnosticsystem
VIChome2026-03-16

Finding into death of John O'Grady

63y · Male·Effects of fire

A 63-year-old man with bipolar disorder, Crohn's disease, ADHD and HIV died in a residential fire at his apartment. He was found with evidence of unsafe smoking in bed, including numerous cigarette butts throughout his u…

general practicepsychiatrysystemrisperidone
VIChospital2026-03-13

Finding into death of Wayne Ronald Watson

61y · Male·Intracranial haemorrhage and myocardial infarct

A 61-year-old man with extensive cardiac disease collapsed at a supermarket, striking his head and losing consciousness for less than 10 seconds. Paramedics identified STEMI and administered heparin on advice from Austin…

cardiologyemergency medicinediagnosticcommunicationheparin
NSWhome2026-03-10

Inquest into the death of Judith Ingham

89y · Female·Burn wounds and the consequences thereof

Judy Ingham, aged 89, suffered severe burns from excessively hot water while bathing in her apartment on 26 August 2022, dying 26 days later from burn wound complications. A licensed plumber failed to install a required …

proceduralsystem
NSW2026-03-06

Inquest into the death of Gregory Merriman

58y · Male·acute myocardial infarction caused by ischaemic heart disease

Gregory Merriman, a 58-year-old Aboriginal man, died from acute myocardial infarction caused by advanced ischaemic heart disease while in custody at Metropolitan Reception and Remand Centre on 27 December 2022. He experi…

cardiologygeneral practicediagnosticcommunicationperindopril
QLDhospital2026-03-06

Non-inquest findings into the death of Ms B

35y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to vertebro…

A 35-year-old woman presented to a rural hospital with a three-day history of collapses, slurred speech, vomiting, and abnormal eye movements. A non-contrast CT head scan was normal, and she was discharged with a diagnos…

emergency medicinegeneral practicediagnosticcommunication
VICcommunity2026-03-05

Finding into death of Yuhan Jin

Female·Hypothermia

Two young Chinese international students died from hypothermia while hiking Mount Bogong in severe weather conditions. They were inexperienced hikers who underestimated the alpine environment's dangers. Despite carrying …

VICcommunity2026-03-05

Finding into death of Yewen Wang

Female·Hypothermia

Two young international students died from hypothermia while hiking Mount Bogong in severe weather conditions (temperatures -3.2 to 8.1°C, heavy snow, poor visibility, high winds). Despite possessing appropriate clothing…

VIChome2026-03-04

Finding into death of Marko Kelentric

73y · Male·Effects of fire

A 73-year-old man died in a residential fire in rural Victoria. He was found unresponsive in his bedroom and declared deceased after fire rescue and paramedic resuscitation attempts. Autopsy confirmed death from smoke in…

systemamitriptyline
VIChome2026-03-04

Finding into death of Ashleigh Peter Mills

57y · Male·Smoke inhalation

Ashleigh Peter Mills, aged 57, died from smoke inhalation in a house fire on 31 August 2020. The fire started from a discarded cigarette in an armchair where his housemate had been smoking and drinking. Multiple preventa…

emergency medicineforensic medicinesystemdelay
VIChome2026-03-04

Finding into death of Carol Fay Slade

54y · Female·Severe burns sustained in a house fire (palliated)

Carol Fay Slade, a 54-year-old woman with acquired brain injury from a 2003 motorcycle accident and mobility limitations, died from severe burns sustained in a house fire at her public housing property in Shepparton. The…

emergency medicineintensive caresystemmethadone
VIChome2026-03-03

Finding into death of Rosendo Ortiz

70y · Male·Smoke inhalation

A 70-year-old man died from smoke inhalation in a residential fire at his public housing unit. He lived in severe hoarding and squalor, without electricity for over three years following a billing dispute. The fire likel…

systemclonazepam
VIChome2026-03-03

Finding into death of Nigel Raymond Willoughby

74y · Male·Complications of burns sustained in a fire

Nigel Willoughby, 74, died from complications of burns sustained in a house fire on 2 September 2020. The fire was caused by a carelessly discarded cigarette igniting an armchair in the lounge room while he was smoking a…

system
VIChome2026-02-27

Finding into death of Maryam Hamka

36y · Female·Unascertained

Maryam Hamka, 36, was killed by her intimate partner Toby Loughnane on 11 April 2021. The coroner found cause of death unascertained due to skeletal remains. Critical systemic failures included: Victoria Police's risk as…

systemcommunication
NSWaged care2026-02-27

Inquest into the deaths of Dimosthenis Gesios and Maureen McGreevy

Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…

Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed bread dipped in Milo by an inexperienced AIN without adequate supervisio…

speech pathologygeneral practicesystemcommunication
TAS2026-02-27

Coroner's Finding: de-identified OR

3y · Male·Multiple blunt force injuries including massive head injury, fractured skull, fr…

A 3-year-old boy died from massive blunt force injuries sustained in a motor vehicle crash when the unsecured child seat in which he was travelling was not anchored to the vehicle. Upon impact with a tree, the child was …

methamphetamine
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