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NSWhospital2025-06-17

Inquest into the Death of Philip William Walker

77y · Male·Aspiration pneumonia complicating retropharyngeal plasmacytoma, cervical myelopa…

Philip Walker, 77, died of aspiration pneumonia complicating retropharyngeal plasmacytoma, cervical myelopathy, COPD and atrial fibrillation while in prison custody. He had complex medical needs including dysphagia from …

respiratory medicineinfectious diseases
WA2025-06-12

Inquest into the Death of Graham John BUTLER

76y · Male·out-of-hospital cardiac arrest in a man with coronary artery atherosclerosis and…

Graham John Butler, aged 76, was a sentenced prisoner at Acacia Prison who died from out-of-hospital cardiac arrest caused by coronary artery atherosclerosis in the context of long-standing type 2 diabetes, hypertension,…

correctional healthgeneral medicinebenzydamine
SAhospital2025-06-11

Coroner's Finding: OHalloran, Emma Louise

48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam

A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…

cardiologygeneral practicesystemcommunicationflecainide
VIChome2025-06-05

Finding into death of Caine David Knight

26y · Male·Cardiomegaly in a man with Prader-Willi syndrome

Caine David Knight, aged 26, died from cardiomegaly with right ventricular hypertrophy in the context of Prader-Willi syndrome and severe obesity. He had a complex medical history including obesity hypoventilation syndro…

cardiologyrespiratory medicinequetiapine
VICaged care2025-05-22

Finding into death of Veronica Lesley Roberts

75y · Female·Ischaemic heart disease in the setting of unstable type 2 diabetes mellitus and …

Veronica Roberts, 75, died from ischaemic heart disease complicated by unstable diabetes and a medication error. On 4 October 2020, her insulin dose was increased to 20 units daily, but due to Electronic Medical Record (…

geriatric medicinegeneral medicinemedicationsystemglargine insulin
VIChospital2025-05-21

Finding into death of Nazlou (Helen) Danilidis

94y · Female·Complications of a fractured neck of femur sustained in an unwitnessed in-hospit…

A 94-year-old woman with significant cardiopulmonary comorbidities died from complications of a fractured femur sustained in an unwitnessed hospital fall. Despite identification as high falls risk and implementation of f…

geriatric medicinecardiologysystemcommunicationlorazepam
SAhospital2025-05-20

Coroner's Finding: Freeman, Keith Vivian

71y · Male·end-stage cardiac failure on a background of ischaemic heart disease with dilate…

Keith Freeman, aged 71, died in custody from end-stage cardiac failure with ischaemic heart disease and dilated cardiomyopathy. He had complex cardiac history including previous CABG, aortic valve replacement, and implan…

cardiologyemergency medicinedelayfurosemide
VICcommunity2025-05-20

Finding into death of Maxine Lorraine Sanderson

61y · Female·Ischaemic heart disease due to coronary artery atherosclerosis

Ms Maxine Lorraine Sanderson, a 61-year-old SDA resident with intellectual disability, died suddenly from ischaemic heart disease due to severe coronary artery atherosclerosis with critical stenosis of the left anterior …

forensic medicinecardiologyvenlafaxine
VIC2025-05-20

Finding into death of Jessica Anne Katgert

41y · Female·Cardiomegaly

Jessica Katgert, aged 41, died in custody at Dame Phyllis Frost Centre from cardiomegaly. She had a history of MSSA infective endocarditis treated in 2021 with echocardiographic changes including dilated left ventricle a…

cardiologyinfectious diseasessystembuprenorphine
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
VIC2025-05-12

Finding into death of Timothy John Hacking

54y · Male·Cardiomyopathy (NOS)

Timothy Hacking, a 54-year-old man with intellectual disability, schizoaffective disorder, epilepsy and hypertension, died suddenly at his supported accommodation from cardiomyopathy. Autopsy revealed moderate coronary a…

cardiologyforensic medicinetelmisartan
TAShospital2025-04-30

Coroner's Finding: Warn, Kenneth

86y · Male·aspiration pneumonia following injuries sustained in a motor vehicle crash and p…

Kenneth Warn, 86, sustained a T12 burst fracture and bilateral pleural effusions from a motor vehicle crash on 1 March 2024 while a passenger in a Mercedes panel van. The driver suddenly lost control on Tea Tree Road; th…

emergency medicineorthopaedic surgery
TAScommunity2025-04-24

Coroner's Finding: de-identified FG

53y · Male·Acute myocardial infarction due to triple vessel atherosclerosis and thrombosis …

A 53-year-old man with chest pain on exertion presented to his GP in March 2022. Initial investigations (blood tests, chest X-ray) were ordered but follow-up was delayed until July 2022. A cardiology referral was made, a…

cardiologygeneral practicediagnosticdelayrosuvastatin
TAShospital2025-04-23

Coroner's Finding: Dow, Vicki Elizabeth

69y · Female·Multiple organ failure due to secondary haemochromatosis (transfusion-associated…

Mrs Vicki Dow, 69, died from multiple organ failure secondary to iron overload (transfusion-associated haemochromatosis) from treatment of myelodysplastic syndrome. She had declined iron chelation therapy for 19 months d…

haematologyemergency medicinecommunicationdiagnosticiron chelation therapy
VIChospital2025-04-11

Finding into death of QB T

64y · Male·Complications of congestive cardiac failure on a background of cardiac hypertrop…

QBT, a 64-year-old man with complex medical and psychiatric history including schizophrenia, COPD, and hypertension, was admitted to Bendigo Hospital on an Assessment Order after police concerns about mental health deter…

psychiatrygeneral medicinediazepam
ACThospital2025-04-09

Inquest Into The Death Of Peter Hanisch

69y · Male·thoracic aortic aneurysm with dissection

Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…

radiologyemergency medicinediagnosticsystem
VIChospital2025-04-03

Finding into death of Alan John Trevor Deem

67y · Male·Intracranial haemorrhage complicating coronary artery bypass graft surgery follo…

A 67-year-old man died from intracranial haemorrhage following coronary artery bypass graft surgery. He had suffered a right coronary artery dissection during percutaneous coronary intervention at Sunshine Hospital and w…

cardiologycardiothoracic surgerycommunicationsystemdual anti-platelet agents
NSWmental health2025-03-28

Inquest into the death of NL

62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval

NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with …

psychiatryendocrinologydiagnosticcommunicationthyroxine
WA2025-03-18

Inquest into the Death of Lex Gregory MAHER

45y · Male·atherosclerotic heart disease

Lex Gregory Maher, a 45-year-old Aboriginal man imprisoned at Greenough Regional Prison, died of atherosclerotic heart disease while playing basketball. He had abnormal ECGs detected in March and May 2022 and was appropr…

cardiologycorrectional healthsystemcommunicationatorvastatin
VIChome2025-03-18

Finding into death of R T

66y · Male·Complications of excess alcohol intake in a man with heart disease

A 66-year-old man died from complications of excess alcohol intake in the setting of underlying heart disease. He had a 40+ year history of heavy daily alcohol consumption (12+ cans of beer plus whiskey daily), chronic p…

general practiceemergency medicinealcohol
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