Coronial
NSW2023-11-16

Inquest into the death of DP

52y · Male·hanging

A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He had requested a CPAP machine for over 9 months without receiving one, which…

psychiatrygeneral practicediagnosticsystemduloxetine
TAShospital2018-01-24

Coroner's Finding: Woolley, Paul James

50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngea…

…ed from pulmonary thromboembolism following uvulopalatopharyngoplasty (UPPP) surgery for obstructive sleep apnoea. Critical failures in post-operative management at a private hospital included: failure to ensure continue…

ENT surgeryanaesthesiacommunicationsystemmorphine
NSWhome2024-08-09

Inquest into the death of Linus Phillips

65y · Male·Cardiac arrhythmia, probably Torsades de Pointes, due to the combined effects of…

…thadone prescribed with inadequate oversight. Mr Phillips had chronic pain from knee surgery, severe sleep apnoea, and was opioid-dependent. Dr H., an addiction specialist, prescribed Physeptone (methadone tablets) start…

general practiceaddiction medicinediagnosticmedicationmethadone
QLDcommunity2016-12-21

Capps, Ruth

75y · Female·multiple injuries due to or as a consequence of motor vehicle collision

…lision after drifting into oncoming traffic. She had multiple medical conditions including diabetes, sleep apnoea, chronic back pain, osteoarthritis, and recurrent falls. Despite a previous licence cancellation in 2012 d…

general practiceoccupational therapydiagnosticcommunicationnitrazepam
ACTcommunity2021-11-15

Inquest into the death of Blake Andrew Corney

4y · Male·fatal head injury sustained as a passenger in a motor vehicle collision

…is stationary family vehicle at an intersection. The driver had undiagnosed or unaddressed suspected sleep apnoea since 2013, did not disclose this condition when renewing his heavy vehicle licence, and failed to attend …

systemcommunication
QLDhospital2012-06-22

Paton, Daniel William

45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia

… wrist plate removal surgery. Multiple contributing factors were identified: undisclosed obstructive sleep apnoea, morbid obesity, possible respiratory infection detected intraoperatively, and post-operative medication m…

anaesthesiapain medicinediagnosticmedicationmorphine
TAShome2023-04-20

Coroner's Finding: Young, Luke Trevor

42y · Male·mixed prescription drug toxicity (sertraline, amlodipine, lamotrigine, quetiapin…

Luke Trevor Young, 42, died from mixed prescription drug toxicity (sertraline, amlodipine, lamotrigine, quetiapine) in a suicide by overdose. He had severe, longstanding bipolar II disorder with chronic suicidality, comp…

psychiatrygeneral practicesystemdelaysertraline
QLDhome2008-09-12

Doheny, Dominic Raphael

36y · Male·morphine toxicity

A 36-year-old man with morbid obesity, possible sleep apnoea, and respiratory symptoms died from morphine toxicity after taking three 100mg MS Contin tablets within 6 …

emergency medicinegeneral practicemedicationprescribingmorphine
SAhospital2014-02-14

Coroner's Finding: RYAN John William and WALTON Patricia Dawn

Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…

Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…

anaesthesiaorthopaedic surgerydiagnosticcommunicationmorphine
VIChospital2025-11-10

Finding into death of Panayotis (Peter) Pavlis

83y · Male·Pneumonia

…entia since 2021, was immobile and bedbound in his final six months, and had comorbidities including sleep apnoea, ischaemic heart disease, and diabetes. On 9 February 2025, nursing staff noted signs of acute deteriorati…

emergency medicinepalliative care
VIC2020-01-29

Finding into death of Prisoner A

55y · Male·Ischaemic heart disease in a man with multiple system atrophy (Parkinsonian type…

A 55-year-old man with ischaemic heart disease and multiple system atrophy (MSA) died suddenly in custody from natural causes. He presented with tremors and collapse in 2017, and was appropriately diagnosed with MSA Park…

cardiologyneurologylevetiracetam
SAhospital2015-03-06

Coroner's Finding: SIMOS Theodoras Joannas

48y · Male·undetermined

A 48-year-old man with schizoaffective disorder, poorly controlled diabetes, sleep apnoea, obesity and cardiomegaly died unexpectedly at a rural hospital following acute psychotic agitation. He ha…

psychiatrygeneral practicesystemdelayhaloperidol
VICaged care2022-02-15

Finding into death of Melissa Cunningham

44y · Female·Complications of a lung abscess with contributing factors of Down's syndrome and…

…drome and severe obesity, died from complications of a lung abscess. She required a CPAP machine for sleep apnoea, prescribed and monitored by Western Health since 2013. Western Health provided explicit cleaning schedule…

respiratory medicinegeriatric medicinesystemcommunication
VIChospital2012-02-27

Finding into death of Laurence Wayne Allen

66y · Male·Aspiration pneumonia in the setting of acute myocardial infarction in a man with…

Laurence Allen, a 66-year-old man with quadraplegia, end-stage renal failure requiring dialysis, and cardiac disease, died of aspiration pneumonia following acute myocardial infarction. He was an inmate at Port Phillip P…

cardiologynephrology
NSWcommunity2014-07-18

Inquest into the death of Pat MORENA

24y · Male·Combination of factors including methylamphetamine toxicity, physical exertion, …

…n of drug offences. He was acutely intoxicated with high-concentration methylamphetamine, obese with sleep apnoea, and became violently resistant during detention. Officers used standard restraint techniques including a …

forensic medicinetoxicologysystemmethamphetamine
VIChospital2026-03-19

Finding into death of Richard Watson

62y · Male·Aspiration pneumonia complicating epilepsy in the setting of Down syndrome

Richard Watson, a 62-year-old man with Down syndrome, epilepsy, dementia and C1 partial quadriplegia, died from aspiration pneumonia at Austin Hospital. He had recurrent admissions over six months for pneumonia, asthma a…

emergency medicinerespiratory medicine
NSWhospital2017-08-21

Inquest into the death of Donald McKinnon

82y · Male·complications of metastatic pancreatic cancer with end stage liver failure

… prison and housed in an Aged Care Unit where his multiple comorbidities (diabetes, cardiac disease, sleep apnoea, dementia) were regularly managed with physiotherapy, occupational therapy and falls prevention. When adva…

oncologygastroenterology
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…

neonatologymidwiferydiagnosticsystem
NSWhospital2014-07-14

Inquest into the death of John McFerrier

51y · Male·Sepsis with multi-organ failure; pneumonia (multi-drug resistant Staphylococcus)…

John McFerrier, a 51-year-old man in immigration detention, died from sepsis with multi-organ failure and multi-drug resistant pneumonia, complicated by morbid obesity. He was admitted to Liverpool Hospital ICU with brea…

intensive careinfectious diseasesantidepressants
WAhospital2019-03-08

Inquest into the Death of Seanpol Martin Padraig O'NEILL

30y · Male·methadone toxicity

A 30-year-old man with schizoaffective disorder, narcolepsy, and obesity died from methadone toxicity while an involuntary psychiatric patient. He was prescribed multiple sedating medications including methadone, benzodi…

psychiatryemergency medicinecommunicationsystemmethadone
134511

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