Coronial
QLD2021-05-04

Hambly, Scott

38y · Male·Aspiration pneumonia

Scott Hambly, a 38-year-old life prisoner with dilated cardiomyopathy, epilepsy, and schizophrenia, died from aspiration pneumonia at Wolston Correctional Centre in December 2018. He was identified as needing cardiology …

cardiologypsychiatrycommunicationsystembisoprolol
QLDhospital2026-07-07

Inquest into the death of Maxwell John Beever

83y · Male·Metastatic melanoma

Maxwell John Beever, aged 83, died from metastatic melanoma on 8 July 2022 while in custody at Robina Hospital. A suspicious skin lesion was documented on 26 February 2021 but not investigated until 26 June 2021, delayin…

emergency medicinegeneral medicinedelaydiagnosticoxycodone
VIChospital2021-03-31

Finding into death of Sarah Louise Rose

40y · Female·Cerebral oedema of unknown aetiology with probable contribution from Hashimoto's…

Sarah Louise Rose, aged 40, died from cerebral oedema of unknown aetiology with probable contribution from Hashimoto's encephalopathy. She had been diagnosed with Hashimoto's thyroiditis in late 2011 and prescribed thyro…

general practiceemergency medicinediagnosticcommunicationthyroxine
TAShospital2023-11-17

Coroner's Finding: Williams, Stewart

54y · Male·Hypoxic/ischaemic brain damage caused by blood loss and airway obstruction due t…

…ad, he deteriorated into cardiac arrest requiring 97 minutes resuscitation, resulting in hypoxic-ischaemic brain injury from which he could not recover.

emergency medicineoral and maxillofacial surgerydiagnosticcommunication
NSW2020-10-23

Inquest into the death of Ye Chiu

67y · Male·Head injuries sustained from a fall from the upstairs landing in Goldsmith G Blo…

Ye Chiu, a 67-year-old Chinese-speaking prisoner on remand, died by suicide in prison on 6 February 2017 after falling head-first from a landing. He had a complex psychiatric history including anxiety, depression, hypona…

psychiatryemergency medicinesystemcommunicationparoxetine
WAhospital2024-05-23

Inquest into the Death of Baby BE (Name Subject to Suppression Order)

<1y · Female·brain death complicating head and neck injury

A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult…

paediatricsneonatologydiagnosticcommunicationmethamphetamine
VIChome2018-10-03

Finding into death of Yvonne Rose Vizard

72y · Female·Obstruction of the airways of the neck

A 72-year-old woman with moderate-severe expressive and receptive dysphasia following an acute left middle cerebral artery stroke died by hanging three months post-discharge from rehabilitation. Critical deficiencies wer…

neurologyrehabilitation medicinediagnosticsystem
VIChospital2015-12-10

Finding into death of Dane Alexander Hortle

2y · Male·Tramadol toxicity in the setting of adenotonsillectomy in a child with Pierre Ro…

…ions. The child deteriorated overnight with respiratory depression, seizures, and severe hypoxic-ischaemic brain injury, leading to death despite intensive care. Key clinical failures included: the prescribing doctor no…

ENT surgerypaediatric surgerymedicationcommunicationtramadol
WAcommunity2019-01-29

Inquest into the Death of Glenn William STRICKLAND

43y · Male·Complications of neck injury; specifically extensive brainstem infarction second…

Glenn William Strickland, an experienced Harley Davidson rider, died from brainstem infarction following severe cervical spinal injury sustained in a motorcycle crash on Julimar Road, We…

emergency medicinetrauma surgerysystemdelay
VIChome2026-04-17

Finding into death of Simon Christopher Gaskill

50y · Male·unascertained

Simon Gaskill, aged 50, was found deceased in sand dunes at Ocean Grove Beach in April 2022 after sleeping rough for months. He had been discharged from hospital in December 2021 following treatment for severe alcohol wi…

emergency medicinegeneral medicinecommunicationsystemalcohol
WAcommunity2014-12-17

Inquest into the Death of BC (Subject to Suppression Order)

5y · Male·Acute meningitis caused by Streptococcus pneumoniae infection

BC was a five-month-old boy born to a mother supported by the Department of Child Protection but not formally placed in state care. In May 2010, he was admitted to Princess Margaret Hospital with splenic abscesses; the u…

paediatricsintensive carediagnosticcommunication
VIChospital2015-07-29

Finding into death of Beatrix Dammers

56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy

A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…

emergency medicineneurologydiagnosticmedicationenoxaparin
QLDhospital2012-02-21

Vaggs, Lyji

28y · Male·hypoxic brain injury sustained during restraint in the foyer of the Acute Mental…

Lyji Vaggs, a 28-year-old Aboriginal man with schizophrenia, died from hypoxic brain injury sustained during restraint at Townsville Hospital's Acute Mental Health Unit on 13 April 2010. He h…

psychiatryemergency medicinediagnosticmedicationolanzapine
WAhome2021-06-22

Inquest into the Death of Child AM (Name Subject to Suppression Order)

3y · Female·bronchopneumonia in an infant with obstructive sleep apnoea

A 3-year-old Aboriginal girl died from bronchopneumonia complicated by severe obstructive sleep apnoea. She had rapid-onset childhood obesity (36 kg at death; normal weight 14-16 kg) with multiple cardiopulmonary complic…

paediatricsrespiratory medicinecommunicationsystem
NSWhome2016-12-08

Inquest into the death of Ezekiel HOWARD

10y · Male·Unascertained - sudden and unexpected death; evidence did not allow determinatio…

…ad episodes of transient neurological symptoms in April-May 2011 that prompted investigation including ECG, MRI, and echocardiogram, but no definitive diagnosis was established. An EEG was recommended but not completed …

paediatricscardiologydiagnosticdelay
TASaged care2023

Coroner's Finding: Tweedie, Valma Ann

72y · Female·Pneumonia following cervical spine injuries sustained in an unwitnessed mechanic…

Valma Ann Tweedie, aged 72, died from pneumonia following cervical spine injuries sustained in an unwitnessed fall at a disability support facility. She had a known history of falls, mobility problems, and probable demen…

emergency medicinetrauma surgerydiagnosticcommunication
WAhome2005-05-01

Inquest into the Death of Christopher Nigel Spinks

35y · Male·Acute Staphylococcus aureus Meningitis

Christopher Nigel Spinks, a 35-year-old tree surgeon, died of acute Staphylococcus aureus meningitis on 3 December 2002. He initially presented on 27 November 2002 with neck pain following a windsurfing accident. Dr R. n…

general practiceemergency medicinediagnosticdelaynurofen plus
QLDhospital2017-06-09

Baby L - Non-inquest findings

<1y · Female·Group B Streptococcus meningitis and sepsis

An 18-day-old baby died from late-onset Group B Streptococcus (GBS) meningitis and sepsis. She was born at a regional private hospital after labour complicated by maternal fever (37.6°C), foetal tachycardia (160-170 bpm)…

obstetricsneonatologycommunicationdiagnostic
QLDhospital2018-05-04

LM - Non-inquest findings

1y · Female·Sepsis (Group A Streptococcus)

A nearly 16-month-old girl died from Group A Streptococcal sepsis after presenting to a regional private hospital emergency department. She had been seen multiple times by different GPs in the preceding weeks with viral …

general practiceemergency medicinediagnosticdelaymupirocin
SAhospital2014-11-14

Coroner's Finding: KEY George Darcy

<1y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…

George Darcy Key, an 8-day-old neonate, died from perinatal hypoxic ischaemic encephalopathy following labour complicated by excessive syntocinon-induced contractions and delayed obstetric intervention. The infant was de…

obstetricsanaesthesiadiagnosticcommunicationoxytocin

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