Coronial
QLD2013-09-11

Morris, David Samuel

57y · Male·Coronary atherosclerosis

David Samuel Morris, aged 57, died from coronary atherosclerosis while in custody at Woodford Correctional Centre on 19 November 2011. He had a significant cardiac history including dilated cardiomyopathy, atrial fibrill…

cardiologyforensic medicinewarfarin
WAhospice2019-05-31

Inquest into the Death of Colin George GRAHAM

56y · Male·disseminated malignancy – known non-small cell carcinoma of lung

Colin George Graham, a 56-year-old Aboriginal man with severe COPD and lung cancer, died of disseminated non-small cell carcinoma while in prison custody receiving palliative care. The coroner found his medical care was …

respiratory medicineoncology
SAhospital2020-07-02

Coroner's Finding: WHATLEY Deborah Rose

55y · Female·ischaemic heart disease complicated by epilepsy, asthma and schizophrenia

A 55-year-old woman with schizophrenia, epilepsy, asthma and COPD presented to hospital with abdominal pain and confusion. Initial ED assessment treated presumed UTI and discharged her. She returned the next day with wor…

emergency medicinepsychiatryclozapine
VIChospital2014-09-10

Finding into death of John William Macfie

73y · Male·complications of lung carcinoma in a man with multiple comorbidities

…ischemic heart disease, prior CABG surgeries, cardiac stents, hypertension, hyperlipidemia) and a chronic smoking history, died from complications of lung carcinoma. A chest X-ray in September 2011 suggested possible un…

respiratory medicineoncologyglyceryl trinitrate
TAShome2022-05-19

Coroner's Finding: Dillon, Kelly John

58y · Male·pulmonary thromboemboli complicating deep venous thrombosis

Kelly John Dillon, a 58-year-old disability support worker, died of pulmonary thromboembolism complicating deep venous thrombosis. Three days before death, he sustained a leg injury at work (chair thrown at his lower leg…

general practiceemergency medicine
VIC2017-05-25

Finding into death of ED

42y · Male·Hypoxic/ischaemic encephalopathy; cardiac arrest; cardiomegaly

… case highlights elevated sudden death risk in schizophrenia due to multiple modifiable factors including smoking, hypertension, obesity, physical inactivity, and substance abuse, coupled with potential medication effec…

psychiatryemergency medicinerisperidone
VIChome2023-12-18

Finding into death of Vivianne May Rodger

54y · Female·Effects of fire in a woman with past right middle cerebral artery territory stro…

A 54-year-old woman with left-sided paralysis from a prior stroke died in a house fire started by smoking in bed. She called emergency services at 2:42am reporting her blanket was on fire, but firefighters atten…

proceduralcommunication
VIC2023-07-12

Finding into death of Carl Anthony Van Der Kaay

50y · Male·Cardiomegaly and ischaemic coronary artery disease

…rs (family history of heart disease, prior coronary stent, diabetes, hypertension, hypercholesterolaemia, smoking) collapsed in cardiac arrest on a V/Line train. Despite immediate CPR by an off-duty cardiac nurse and su…

cardiologyemergency medicinesystembisoprolol
SA2019-05-14

Coroner's Finding: ABDULLA Gilbert William Victor

31y · Male·ischaemic heart disease

…the deceased repeatedly refused to comply with prescribed medications, fluid restriction, dietary advice, smoking cessation, and weight management. He was transferred between prisons for rehabilitation programs and ther…

cardiologyemergency medicine
NSWhome2021-12-20

Inquest into the death of Harland SUTTON

5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained

… objects combined with identified SUDI risk factors including prematurity, low birth weight, and paternal smoking. Key clinical lessons include the importance of accurate medication records, proper management of dangero…

paediatricsemergency medicinesystemmedicationfurosemide
TAShospital2021-12-13

Coroner's Finding: Barnett Catherine Diana

55y · Female·acute myocardial infarction due to right coronary artery thrombosis

…visor noted that her symptoms strongly indicated possible acute coronary syndrome, particularly given her smoking history. She returned three days later in shock and suffered fatal cardiac arrest from acute myocardial i…

emergency medicinecardiologydiagnosticdelay
VIChome2025-07-03

Finding into death of Stephanie Rebernik

69y · Female·Effects of fire

…line, poor risk identification, and a documented five-year history of unsafe fire-lighting behaviours and smoking in bed. One month before death, she had deliberately set fire to her bed. Her NDIS disability support pro…

occupational therapypsychiatrysystemdelayoxazepam
NSWhome2024-03-21

Inquest into the death of Brandon Rich

29y · Male·cardiac arrhythmia triggered by myocardial ischaemia arising from physical exert…

…home. He had undiagnosed severe coronary artery disease (75-90% narrowing), morbid obesity, hypertension, smoking history, prior methamphetamine use, and probable schizophrenia. Police attended to serve a domestic viole…

cardiologypsychiatrycommunicationsystemmethamphetamine
VICcommunity2014-12-12

Finding into death of John Raymond Gilbett

54y · Male·hanging

…nd chronic mental illness from a 2001 motor vehicle accident. His GP prescribed varenicline (Champix) for smoking cessation in February 2011; he self-recommenced in late August. His ex-wife reported dramatic mood change…

general practicepsychiatryvarenicline
VIChome2026-05-19

Finding into death of UYB UYB

11y · Male·Effects of fire

…rinkler systems in all new residential buildings; and intensifying public awareness about fire safety and smoking risks.

pathology
VIChospital2012-01-31

Finding into death of Lee Patrica Collings

51y · Female·Multiple injuries sustained when struck by a car while lying on the Mornington P…

…cords; her recent history would have warranted higher triage category; and she was permitted unsupervised smoking breaks despite high suicide risk. The clinician delayed formal risk assessment until she was sober, but a…

emergency medicinepsychiatrycommunicationsystemsodium valproate
TAShome2025-08-05

Coroner's Finding: Iliev, Patricia

57y · Female·starvation due to insufficient food intake

…mmobilised by chronic back pain. She had a gastrointestinal stromal tumour and advanced lung disease from smoking. Her partner, Philip Adams, provided food and care as requested but did not intervene when she stopped ea…

general practicepsychiatrysystemdelayaspirin
NThospital2015-11-25

Inquest into the death of Angus Dixon

59y · Male·Cardiac arrest caused by Ischaemic Heart Disease

…gations were underway to exclude organic causes. On 20 December, he suffered a fatal cardiac arrest while smoking outside the hospital. The death was not initially recognised as reportable because his involuntary status…

psychiatryemergency medicinecommunicationsystem
WAhospital2023-01-11

Inquest into the Death of Colin Albert WINTER

71y · Male·End-stage chronic obstructive pulmonary disease and atherosclerotic heart diseas…

…en hospital and custodial services have discordant expectations; (2) Winter's entrenched refusal to cease smoking despite repeated medical advice significantly contributed to progression of COPD, ischaemic heart disease…

respiratory medicinecardiologycommunicationsystem
VIChospital2012-02-06

Finding into death of David Crisfield

43y · Male·Septic shock from streptococcus pneumoniae sepsis arising from streptococcus pne…

…d him from across the room without examination, dismissing him as Category 5, influenced by the patient's smoking and drinking history rather than objective clinical assessment. The patient was discharged and seen next …

emergency medicinegeneral practicediagnosticcommunicationsalbutamol
145615

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