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NSWhospital2025-05-15

Inquest into the death of Francis Cable

90y · Male·pneumonia complicating ischaemic heart disease

Francis William Athol Cable, aged 90, died in the Corrective Services NSW Secure Annex at Prince of Wales Hospital on 12 September 2022. He had complex medical comorbidities including ischaemic heart disease, chronic car…

cardiologyrespiratory medicine
VIC2025-05-14

Finding into death of Adrian Colin Phillips

58y · Male·Complications of community-acquired pneumonia, in a man with chronic lung diseas…

Adrian Phillips, a 58-year-old man with intellectual disability and chronic lung disease (emphysema, bronchopulmonary aspergillosis, asthma), died from community-acquired pneumonia caused by MRSA and Rhinovirus. He prese…

general practicerespiratory medicinebromhexine
VIChospital2025-05-12

Finding into death of Desmond Alick Budge

63y · Male·Aspiration pneumonia in a man with trisomy 21, Alzheimer's dementia and other me…

A 63-year-old man with trisomy 21 and advanced Alzheimer's dementia died from aspiration pneumonia while receiving specialist disability accommodation. He presented to hospital on 8 September 2024 with hypoxia and tachyp…

respiratory medicinegeriatric medicine
WAhospital2025-04-17

Inquest into the Deaths of HC and Child HR

terminal palliative care in a girl with a clinical diagnosis of aspiration pneum…

A 12-year-old girl with severe cerebral palsy (quadriplegia) died from aspiration pneumonia whilst in state care following removal from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence,…

paediatricspalliative care
VIC2025-04-04

Finding into death of John Stuart Richards

81y · Male·Lung cancer

An 81-year-old man with advanced lung cancer and multiple comorbidities died of natural causes while receiving palliative care in prison. He had documented his wishes for comfort-focused care and was registered on the DN…

palliative caregeneral practice
VIChospital2025-04-01

Finding into death of ZSQ

81y · Male·Community acquired pneumonia in a man with acute on chronic renal failure

An 81-year-old man with chronic respiratory disease and renal failure died from community-acquired pneumonia complicated by acute-on-chronic renal failure. He presented to hospital on 25 April 2023 with respiratory failu…

intensive carerespiratory medicinediagnosticdelayadrenaline
VIChome2025-04-01

Finding into death of Andrew Cameron McDougall

57y · Male·Bilateral bronchopneumonia in a man with asthma, tetraplegia and multiple other …

Andrew McDougall, 57, a man with complex medical comorbidities including tetraplegia, COPD, asthma, ischaemic heart disease and diabetes, died from bilateral bronchopneumonia at his supported disability accommodation hom…

respiratory medicinegeneral practiceoxycodone
VIC2025-03-31

Finding into death of George Platakis

54y · Male·Klebsiella pneumoniae pneumonia in a man with Huntington's Disease, with contrib…

George Platakis, a 54-year-old man with Huntington's Disease and COPD, died from Klebsiella pneumoniae pneumonia while residing in specialist disability accommodation. He had sustained a serious fall in January 2023 caus…

neurologyrespiratory medicine
VIChome2025-03-12

Finding into death of H D

11y · Female·Pneumonia complicating cerebral palsy secondary to KCNQ2 developmental and epile…

HD was an 11-year-old girl with severe cerebral palsy, epilepsy, and multiple complex medical conditions including central respiratory depression and recurrent chest infections. She died from pneumonia at home in August …

paediatricspalliative care
VIChospital2025-03-07

Finding into death of Heather Joan Moody

77y · Female·Pneumonia with contributing factors of acquired brain injury, Parkinson's diseas…

A 77-year-old woman with acquired brain injury, Parkinson's disease, epilepsy and intellectual disability died of pneumonia while an SDA resident. She presented with breakthrough seizures and aspiration pneumonitis on 16…

neurologyrespiratory medicineprednisolone
VICmental health2025-02-27

Finding into death of Judith Mary Pollard

73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…

Judith Pollard, a 73-year-old woman with an extensive mental health history, was voluntarily admitted to Shepparton Private Hospital on 1 June 2023 following acute depression and paranoia. Despite her family informing st…

psychiatryemergency medicinesystemcommunicationamitriptyline
VIChospital2025-02-27

Finding into death of Steven John Parlby

73y · Male·Complications of multiple injuries sustained in a motor vehicle incident (car vs…

A 73-year-old man with extensive medical comorbidities including severe biventricular heart failure, COPD, sleep apnoea, and hypertension experienced a medical episode while driving, causing him to cross into oncoming tr…

general practicecardiologysystemcommunicationvalsartan
VIChospital2025-02-26

Finding into death of CFT

78y · Female·Bronchopneumonia

CFT, a 78-year-old woman with chronic schizophrenia, intellectual disability, and dementia, died of bronchopneumonia with hypothermia and coronary atherosclerosis. She lived with her nephew RDS who was her carer. Multipl…

geriatric medicinegeneral practicediagnosticsystem
VIChospital2025-02-24

Finding into death of Anne-Maree Tammy Carr

44y · Female·COVID-19

Ms Anne-Maree Tammy Carr, a 44-year-old woman with intellectual disability, cerebral palsy, diabetes, and high cholesterol living in Specialist Disability Accommodation, died from COVID-19 pneumonia on 6 October 2024, fo…

general practiceinfectious diseases
NSWhospital2025-02-21

Inquest into the death of David Freeman

46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…

A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…

emergency medicinegeneral practicediagnosticmedicationaspirin
VIChospital2025-02-12

Finding into death of Alexander Cameron

40y · Male·Aspiration pneumonia

Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia f…

intensive caregeneral surgeryclozapine
VIChome2025-01-22

Finding into death of Neil Douglas Heaton

67y · Male·Pneumonia in the setting of aspiration and posterior rib fractures

Neil Douglas Heaton, a 67-year-old man with intellectual disability, dementia, and aspiration risk factors, died from pneumonia complicated by posterior rib fractures of unclear origin. He was found unresponsive at his s…

forensic medicineemergency medicine
VIChospital2025-01-08

Finding into death of Mark Ruth

50y · Male·Sepsis of unknown organism in respiratory

Mark Ruth, a 50-year-old NDIS participant with cerebral palsy, intellectual disability, chronic dysphagia, and obstructive sleep apnoea, died from sepsis of unknown respiratory organism. He had experienced declining heal…

emergency medicinerespiratory medicinesodium valproate
VIChospital2025-01-06

Finding into death of Leah Pollauszach

54y · Female·Aspiration pneumonia with antecedent causes of oropharyngeal dysphagia and a sig…

Ms Pollauszach, a 54-year-old woman with Down Syndrome (Trisomy 21) and oropharyngeal dysphagia, died from aspiration pneumonia following admission to Northern Hospital. The coroner found no clinical management failures …

general medicinerespiratory medicine
WA2024-12-23

Inquest into the Death of Frank MIKHAIL

68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…

Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…

respiratory medicineemergency medicinediagnosticcommunicationamitriptyline
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