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QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypic…

emergency medicineinfectious diseasesdiagnosticdelayantacid
QLDmental health2013-07-02

Justin

35y · Male·Choking due to impaction of soap in airway

A 35-year-old man with treatment-resistant depression and complex psychiatric presentation died from choking on a bar of soap while in involuntary psychiatric care. He had attempted multiple suicides previously. Clinical…

psychiatryintensive caresystemcommunicationrisperidone
TAShospital2023-05-05

Coroner's Finding: Pedler, Anne Helen

71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis

…to ED with signs of circulatory failure (hypotension, tachycardia, tachypnoea, hypoxia) and progressive leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pulmonary embolism; bedside ultrasound sh…

emergency medicinecardiologydiagnosticdelaycannabis oil
VIChospital2013-08-13

Finding into death of Thelma Katherine Holt

79y · Female·pneumonia in the setting of acute peritonitis due to perforated stomach (operate…

…tember 2008 for weight loss prior to hernia repair. On 30 January 2009, she presented with severe abdominal pain and vomiting. CT imaging confirmed gastric outlet obstruction from the balloon. Despite this, her gastroent…

gastroenterologygeneral surgerydiagnosticproceduralsertraline
WAhome2015-06-08

Inquest into the Death of Baby P

0y · Male·intrapartum hypoxia due to placental abruption

A second twin boy was born at home despite medical advice that twin pregnancies require hospital care. The mother, who strongly preferred home birth, disengaged from hospital when her preferences for birth management (va…

obstetricsmidwiferycommunicationdelay
NSWcommunity2023-08-08

Inquest into the death of Simon Miles

42y · Male·heroin and methylamphetamine toxicity

Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing…

addiction medicinepsychiatrysystemcommunicationheroin
WAhospital2023-06-29

Inquest into the Death of Child R (Name Subject to Suppression Order)

11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…

…sing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and vomiting. She died 12 hours later from E. coli sepsis associated with intestinal obstruction due to fae…

paediatricsemergency medicinediagnosticcommunicationmacrogol
QLDhospital2014-08-05

Olive, Thomas (Tom) Andrew

4y · Male·Severe rhabdomyolysis due to LPIN1 gene mutation

…PIN1 gene mutation. Over 12 months before death, he presented with recurrent episodes of dark urine, muscle pain, and lethargy. Multiple GPs and a paediatrician investigated but failed to recognise the pattern. On 30 Jun…

general practiceemergency medicinediagnosticcommunicationsuxamethonium chloride
QLDhospital2024-11-08

Non-inquest findings into the death of SD

61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed

A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…

haematologypathologydiagnosticcommunicationprednisolone
VIC2020-04-06

Finding into death of Darren Brandon

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

Darren Brandon died by hanging in prison on 10 June 2018, two days after arriving at Melbourne Assessment Prison. He was a 51-year-old man with acquired brain injury from a 2003 motorcycle accident, depression, and histo…

psychiatryforensic medicinecommunicationsystemoxycodone
WAhospital2005-09

Inquest into the Death of Maria Donatelli

72y · Female·Peritonitis due to perforated diverticulum in transverse colon

…natelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially managed conservatively with a provisional diagnosis of pancreatitis or bowe…

general surgeryemergency medicinediagnosticcommunicationtramadol
VICaged care2019-02-04

Finding into death of Margaret Elizabeth Barton

83y · Female·Pneumonia complicating rib and pelvic fractures sustained in the setting of mult…

…s such. (3) Fractures from falls were not identified radiologically until late hospital admission, delaying pain management. (4) Poor handover between facilities prevented essential clinical information transfer. (5) Mul…

general practicegeriatric medicinemedicationcommunicationoxazepam
WAhospitalAugust 2023

Inquest into the Death of Justin DOBSON

46y · Male·sepsis following haemorrhoidectomy

…transfer to a tertiary hospital should have occurred. Instead, the clinical deterioration was attributed to pain, anxiety, and medication effects. A MET call was not made until 9:30 pm when Mr Dobson was in profound sept…

general surgerycolorectal surgerydiagnosticcommunicationmetronidazole
QLDhospital2007-08-10

Tang, Shannon Sheng Wen

21y · Male·multi-organ failure due to septicaemia of mixed respiratory (bronchopneumonia) a…

Shannon Tang, a 21-year-old from Singapore with severe obesity (BMI 52) and multiple comorbidities including sleep apnoea, underwent elective laparoscopic gastric bypass surgery performed by Dr F.. He died on day 7 post-…

bariatric surgerygeneral surgerycommunicationdiagnosticvancomycin
VIChome2023-01-30

Finding into death of Veronica Nelson

37y · Female·complications of withdrawal from chronic opiate use and Wilkie Syndrome in the s…

…sferred to mainstream prison on 1 January 2020 despite remaining unwell. On 2 January 2020, while in severe pain and distress overnight, Veronica received minimal assessment and support from night nurse RN George and pri…

general practiceaddiction medicinediagnosticsystembuprenorphine/naloxone
VIChospital2024-05-24

Finding into death of Jacob William Kennedy

36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…

Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He was administered multiple s…

psychiatryaddiction medicinemedicationproceduralmethadone
SAcommunity2025-10-17

Coroner's Finding: Hall, Robert Lloyd

66y · Male·multiple injuries sustained in motor vehicle collision

A 66-year-old cyclist was struck and killed from behind by a driver with left absolute homonymous hemianopia (left-sided visual field loss) who was not scanning to compensate for his disability. The driver had suffered a…

neurosurgeryneurologysystemcommunication
NSWhospital2026-03-19

Inquest into the death of Eve Brown

42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…

… was admitted to Lightning Ridge Multi-Purpose Centre despite clinical features (severe vomiting, abdominal pain, elevated temperature) warranting transfer to Dubbo Base Hospital for CT imaging to exclude serious differe…

emergency medicinegeneral practicediagnosticcommunicationceftriaxone
WAhospital2010-03-03

Inquest into the Death of McLevie

38y · Female·Streptococcus Group A Septicaemia (Post Partum-Puerperal Sepsis)

…ltiple clinical warning signs including repeated elevated temperatures (38.7°C at 6:50am), severe abdominal pain, low blood pressure (80/60 at ~4:45pm), and low urine output, she was never prescribed antibiotics during h…

obstetricsmidwiferydiagnosticcommunicationparacetamol/codeine
NSW2020-03-25

Inquest into the death of Mahmoud ALLAM

28y · Male·MRSA sepsis

… presented with upper respiratory symptoms on 11 June 2016, followed by increasing symptoms including chest pain and facial cellulitis. Nursing assessments on 13-14 June were considered adequate at the time, though a mis…

infectious diseasesemergency medicinecommunicationsystemflucloxacillin

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