Coronial
VIChospital2024-09-24

Finding into death of Jessica Nyla Louis

32y · Female·Perforation of the bowel in the context of constipation and intellectual disabil…

Jessica Louis, a 32-year-old non-verbal woman with intellectual disability and Opitz Trigonocephaly Syndrome, died from bowel perforation secondary to severe constipation and pica (compulsive ingestion of non-food items)…

surgeryemergency medicine
VIChospital2024-04-11

Finding into death of Mark Andrew Spillane

58y · Male·Septic shock secondary to intra-abdominal collections as sequelae of osteomyelit…

A 58-year-old man with Down syndrome and multiple comorbidities died from septic shock secondary to intra-abdominal collections caused by osteomyelitis/discitis of the spine. He initially presented with a foot bone infec…

infectious diseasesgeneral medicine
NSWhospital2026-05-15

Inquest into the death of Robert Bell-Williams

71y · Male·metastatic papillary renal cell carcinoma

Robert Bell-Williams, aged 71, died from metastatic papillary renal cell carcinoma while in lawful custody at Long Bay Hospital on 1 February 2024. Imprisoned since 2012, he was diagnosed with renal cell carcinoma in 202…

oncologypalliative carecabozantinib
VIChome2010-11-05

Finding into death of Veronica Therese Campbell

38y · Female·complications following a ruptured ectopic pregnancy

… requests from hospital staff to upgrade to Code 1 priority when her condition deteriorated (hypotension, anaemia, blood loss), dispatchers failed to record clinical information or respond appropriately. Significant del…

emergency medicineobstetricscommunicationdelaymorphine
VIChospital2025-08-19

Finding into death of Con Koumis

43y · Male·complications of decompensated liver failure due to occult sepsis and retroperit…

Con Koumis, a 43-year-old man with beta-thalassaemia major requiring regular blood transfusions, died from decompensated liver failure complicated by occult sepsis and retroperitoneal haemorrhage. He was remanded in cust…

haematologyhepatology
SA2021-11-25

Coroner's Finding: Clark, Murray Eric

81y · Male·valvular heart disease with cardiac amyloidosis

Murray Eric Clark, 81-year-old prisoner with extensive cardiac history including aortic stenosis, sick sinus syndrome with pacemaker, and recent TAVI procedure, collapsed and died in prison infirmary on 20 September 2019…

cardiologyemergency medicineanticoagulants
SAhospital2014-05-19

Coroner's Finding: DONNELL Kevin George

60y · Male·end stage refractory chronic congestive cardiac failure on a background of chron…

A 60-year-old man with chronic schizophrenia, end-stage cardiac failure, renal failure, and dementia died of refractory congestive heart failure while under Mental Health Act detention. He had multiple comorbidities incl…

cardiologypsychiatry
SAhospital2026-02-26

Coroner's Finding: Lowery, Nahuel Sebastian

41y · Male·Acute liver failure with contributing Castleman's disease

A 41-year-old Aboriginal man with HIV and Castleman's disease died from acute liver failure while on home detention. He had variable compliance with antiretroviral therapy, exacerbated by amphetamine use disorder and men…

infectious diseasesintensive careantiretroviral therapy
SAhospital2022-03-29

Coroner's Finding: Foster, Clive Anthony

76y · Male·end-stage renal failure

A 76-year-old man died of end-stage renal failure while imprisoned. He had pre-existing hypertension, diabetes, and stage 3 chronic kidney disease. During his final year in custody, he experienced acute kidney injury sup…

general medicinenephrology
WAhospital2020-06-03

Inquest into the Death of Michael Warren DYBALL

56y · Male·bronchopneumonia complicated by multiorgan failure and hypoxic ischaemic encepha…

Michael Dyball, a 56-year-old prisoner with chronic kidney disease, hepatitis C, and treated oropharyngeal squamous cell carcinoma, collapsed in his prison cell and suffered cardiopulmonary arrest on 28 April 2016. He di…

nephrologyoncologydarbepoetin alfa
VIChospital2018-08-27

Finding into death of PH

51y · Male·Complications of aspiration pneumonia in a man with status epilepticus

A 51-year-old man with Lennox-Gastaut syndrome, intellectual disability, and recurrent aspiration pneumonia died from complications of aspiration pneumonia and status epilepticus. He presented with status epilepticus and…

neurologyintensive careanticonvulsant medications
WAhospital2019-03-12

Inquest into the Death of Lorna May WOODS

39y · Female·pulmonary thromboembolism due to deep vein thrombosis and sepsis due to pyelonep…

Lorna May Woods, 39, died from pulmonary thromboembolism due to deep vein thrombosis and sepsis secondary to pyelonephritis on a background of metastatic ovarian cancer. She presented to Joondalup Health Campus with uros…

emergency medicinepsychiatryheparin
SAhospital2005-04-07

Coroner's Finding: MULVINSKAS Anna

79y · Female·pulmonary oedema and electrolyte imbalance, both secondary to renal failure

Mrs Mulvinskas, a 79-year-old with end-stage renal disease, renal carcinoma, diabetes, and cardiac failure, died from pulmonary oedema and electrolyte imbalance secondary to renal failure. On 21 October 2004, she became …

general medicinenephrologycalcium
NSWhospital2019-05-14

Inquest into the death of Shaun BELL

4y · Male·Peritoneal sepsis caused by a perforated duodenal ulcer

A 4-year-old boy with significant global developmental delay and non-verbal communication died from peritoneal sepsis caused by a perforated duodenal ulcer. Presentation included lethargy, poor oral intake, low haemoglob…

emergency medicinepaediatricsdiagnosticcommunication
VIChospital2016-10-24

Finding into death of Child A

3y · Male·thrombotic microangiopathy

A 3-year-old child died from thrombotic microangiopathy (haemolytic uraemic syndrome) secondary to Shiga toxin-producing E. coli infection, likely acquired from consumption of unpasteurised milk. Early presentation to GP…

paediatricsemergency medicineondansetron
TAShospital2019-01-31

Coroner's Finding: Skrepetos, Stavroula

80y · Female·Haemoperitoneum/retroperitoneal haematoma due to rupture of the abdominal aorta …

…d antibiotics. She appeared to stabilize but deteriorated further at 11am with severe hypotension, severe anaemia, and metabolic acidosis. Resuscitation failed and she died. Autopsy revealed a ruptured infra-renal abdom…

emergency medicinegeneral medicinediagnosticintravenous fluids
WA2019-06-19

Inquest into the Death of Malcolm Patrick O'DRISCOLL

66y · Male·acute myocardial infarction on a background of atherosclerotic cardiovascular di…

Malcolm Patrick O'Driscoll, a 66-year-old life-sentenced prisoner, died on 15 April 2017 at Acacia Prison from acute myocardial infarction on a background of severe atherosclerotic cardiovascular disease. He had been imp…

cardiologyvascular surgery
QLDhospital2019-12-05

Burrows, Frank Leslie

58y · Male·Haemophagocytic lymphohistiocytosis, due to or as a consequence of T-cell lympho…

Frank Burrows, a 58-year-old male prisoner, died from Haemophagocytic Lymphohistiocytosis (HLH) secondary to T-cell lymphoma. He presented with non-specific symptoms (fever, sweats, diarrhoea) and was initially discharge…

general medicinehaematologydexamethasone
TAShome2021-04-12

Coroner's Finding: Rubenach, Timothy Luke

32y · Male·Aspiration pneumonia and reflux oesophagitis

Timothy Luke Rubenach, aged 32, died of aspiration pneumonia following severe reflux oesophagitis. He had profound intellectual disability and drug-resistant epilepsy from meningococcal infection at 5 months. His parents…

general practicegastroenterologymorphine
SAcommunity2011-05-12

Coroner's Finding: KILTIE Andrew

52y · Male·clozapine toxicity

Andrew Kiltie, 52-year-old Aboriginal man, died from clozapine toxicity on 26 December 2007. He had been on clozapine 400mg daily for 5 years with significant clinical benefit for aggressive behaviour and psychosis, enab…

psychiatrycardiologyclozapine
145610

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