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VIChospital2022-10-06

Finding into death of Tracey Lee Cooke

55y · Female·aspiration pneumonia

Tracey Lee Cooke, a 55-year-old woman with severe intellectual disability, Parkinson's disease, and dysphagia, died from aspiration pneumonia at Footscray Hospital. She had five documented aspiration pneumonia episodes i…

respiratory medicinepalliative caresystemcommunication
NT2020-08-18

Inquest into the death of David Loader

58y · Male·carcinomatosis from unknown primary

David Kevin Loader, a 58-year-old life prisoner, died from metastatic cancer of unknown primary in January 2020. He presented with multiple episodes of back, abdominal, shoulder and rib pain between July and November 201…

general practiceoncologysodium valporate
NSWaged care2017-04-06

Inquest into the death of AR

29y · Male·Unascertained

AR was a 29-year-old man with autism, developmental disability and epilepsy living in a residential disability care facility. He was found unconscious and died suddenly on 30 August 2010. Initial post-mortem findings sug…

neurologypsychiatrydelayfluvoxamine
VIChome2024-06-11

Finding into death of Martin Page

39y · Male·most likely suicide; possibly accidental death from untreated epilepsy or natura…

Martin Page, a 39-year-old man with epilepsy, schizophrenia or Asperger's syndrome, severe obsessive-compulsive behaviours, and intellectual disability, disappeared from his family home in October 2006 and has not been l…

psychiatryneurologysystemdelay
VIC2020-04-06

Finding into death of Darren Brandon

51y · Male·hypoxic-ischemic encephalopathy due to hanging

… Assessment Prison. He was a 51-year-old man with acquired brain injury from a 2003 motorcycle accident, depression, and history of suicide attempts. Critical information about his mental health and vulnerability was not…

psychiatryforensic medicinecommunicationsystemoxycodone
WAhome2016-09-30

Inquest into the Death of Janene DEVINE

48y · Female·malnutrition in association with sepsis on a background of end stage multiple sc…

A 48-year-old woman with end-stage multiple sclerosis died from malnutrition and sepsis after her husband, her primary carer, failed to provide adequate nutrition via a PEG tube despite receiving training and instruction…

neurologygastroenterologysystemdelay
VICcommunity2025-08-27

Finding into death of Harley James Smith

7y · Male·multiple injuries sustained in a motor vehicle collision (passenger)

A 7-year-old boy died in a head-on motor vehicle collision after his father deliberately drove their newly purchased car into an oncoming truck. The father had recently experienced severe stress following his partner's d…

paediatricspsychiatrycommunicationsystemmirtazapine
QLDhospital2012-12-07

Cooper, Gerry Maxwell

57y · Male·Hepatic encephalopathy, end stage liver failure, alcoholic cirrhosis, end stage …

Gerry Maxwell Cooper, a 57-year-old Aboriginal man imprisoned for 23 years, died in PAH Secure Unit from natural causes: hepatic encephalopathy, end-stage liver failure, alcoholic cirrhosis, and end-stage renal failure. …

nephrologyhepatologysystemasasantin
VIChospital2025-08-18

Finding into death of B T

53y · Male·Complications of hypoxic brain injury secondary to mixed drug toxicity (methylam…

BT, a 53-year-old man with substance use disorder and mental health conditions, died from complications of hypoxic brain injury secondary to mixed drug toxicity (methylamphetamine, benzodiazepines, metonitazene). He inje…

emergency medicineintensive caremethamphetamine
WAhospital2016-11-16

Inquest into the Death of Shannon Elizabeth MURPHY

33y · Female·Methylamphetamine intoxication leading to agitated delirium and extreme exertion…

A 33-year-old female with a history of methylamphetamine use consumed the drug and became acutely intoxicated, exhibiting agitated delirium and bizarre behaviour searching for her son. She was violently assaulted by resi…

emergency medicinetoxicologymethamphetamine
ACTaged care2003-08-04

Inquest Into The Manner And Cause Of Death Of Ivy Pearl Ghobrial

Female·bilateral acute bronchopneumonia

Ivy Pearl Ghobrial died from bilateral acute bronchopneumonia at a nursing home in September 2001, following a hypoxic brain injury sustained from a hanging attempt in March 2000. The coroner found the death resulted ine…

psychiatryneurology
WAhome2014-10-17

Inquest into the Death of Ethan (Subject to a Suppression Order)

15y · Male·Ligature compression of the neck (hanging)

A 15-year-old Aboriginal boy in foster care died by suicide following apparent impulsive response to adolescent boundary conflicts. Despite stable, loving foster placement since age 4, Ethan remained neurologically vulne…

psychiatrypsychologymelatonin
SAaged care2008-11-06

Coroner's Finding: CECERE Rolando

71y · Male·Positional asphyxia

A 71-year-old man with severe dementia died from positional asphyxia when his neck became wedged in a gate at an aged care facility. He had demonstrated multiple escape attempts within days of admission, with staff docum…

geriatric medicinepsychiatrysystemdelay
VIChome2023-05-04

Finding into death of Jodie Overstead

34y · Female·Multi drug toxicity

Jodie Overstead, a 34-year-old with epilepsy, anxiety, and chronic pain, died from multi-drug toxicity involving tramadol, codeine, amitriptyline, benzodiazepines and other drugs. She engaged in 'doctor shopping', obtain…

general practicepain medicinediagnosticmedicationtramadol
VIChospital2021-04-08

Finding into death of Ian Lindsay Gould

64y · Male·Complications of Creutzfeldt-Jakob Disease following a fall

…cal and ophthalmological evaluation was normal; functional visual loss was suspected. He developed major depression with suicidal ideation and was admitted to an acute mental health unit. On 7 August, he fell backwards, …

neurologyophthalmologysystemrivaroxaban
VIChome2025-01-28

Finding into death of Edward Grant Harris

18y · Male·Heroin toxicity

Edward Grant Harris, an 18-year-old with autism spectrum disorder, ADHD, and borderline intellectual function, died from heroin toxicity in his supported accommodation. He had a complex history of behavioural challenges,…

paediatricspsychiatrysystemheroin
QLDcommunity2021-09-10

Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings

49y · Female and male·Gunshot wound to head inflicted by spouse

Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…

general practicepsychiatrydiagnosticcommunicationcannabis
QLDmental health2006-09-08

Robinson, Terence James

54y · Male·Global cerebral hypoxic injury due to or as a consequence of status epilepticus

Terence James Robinson, 54, died from status epilepticus causing global cerebral hypoxic injury after 16 days at Belmont Private Hospital. He was admitted following a violent altercation with police and attempted suicide…

psychiatryneurologydiagnosticcommunicationparoxetine
QLDhospital2024-03-07

KLUMPER Joshua William

17y · Male·Hanging

17-year-old Joshua Klumper died by hanging following cannabis withdrawal and workplace stress. He had a complex mental health history with ASD diagnosis (lacking robust diagnostic support), multiple suicide attempts, and…

psychiatryemergency medicinecommunicationsystemcannabis
QLDaged care2018-06-05

Milward, Paul Joseph

53y · Male·Choking on food bolus in pharynx, with Huntington's disease and coronary atheros…

Paul Joseph Milward, aged 53 with Huntington's disease causing cognitive impairment and swallowing difficulties, died from choking on a bread sandwich while unsupervised in his aged care room. His care plan specified min…

geriatric medicinespeech pathologycommunicationsystemsodium valproate

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