Coronial

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SAhome2012-06-06

Coroner's Finding: Home Birthing - SPENCER-KOCH Tate and HOBBS Jahli Jean and KAVANAGH Tully Oliver

Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: in…

Three neonates died following complications during planned homebirths attended by midwife Lisa Barrett. Tate Spencer-Koch (4790g, macrosomic) died from intrapartum hypoxia caused by shoulder dystocia; delivery was obstru…

obstetricsmidwiferydiagnosticcommunication
WAhospital2004-06-17

Inquest into the Death of Edmiston

41y · Female·Peritonitis following surgical procedure to the urinary bladder, due to infected…

… not reviewed by medical staff for 22 hours post-procedure despite warning signs including fever, abdominal pain, absent urine output, and abnormal bladder scans. When antibiotics were finally ordered at 10am on day two,…

urologygeneral surgerydiagnosticmedicationamoxicillin
NSWhospital2018-10-22

Inquest into the death of Sandra Cree

71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…

…e Service) in early April 2016 with classic symptoms of AAA rupture: hypotension, shock, abdominal and back pain. Critical clinical lessons emerged: (1) Dr K. at Lightning Ridge made the correct diagnosis but lacked acce…

emergency medicinevascular surgerydiagnosticcommunicationgentamicin
TAS2026-06-03

Coroner's Finding: Brown, Nicholas, Wiki, Toni, Winwood, Matthew and Kemp, Belinda

Male, female, male, female·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …

Joint inquest into four deaths of individuals prescribed opioid replacement therapy by Dr J. between September 2016 and August 2017: Nicholas Shane Brown (35), Toni Lee Wiki (38), Matthew Wayne Winwood (47), and Belinda …

addiction medicinegeneral practicediagnosticmedicationmethadone
WAhospital2013-01-17

Inquest into the Death of Mckay-Hall, Julienne Maria

46y · Female·Complications following cardiorespiratory arrest in association with an air embo…

… to read nursing notes documenting signs of sepsis (green bile drainage, elevated vital signs, shoulder tip pain), instead documenting her as 'stable'. On 12 November, critical observations showing respiratory distress (…

general surgerybariatric surgerydiagnosticcommunicationmorphine
SAhospital2020-08-04

Coroner's Finding: WILLMETT Laura Angela

0y · Female·hypoxic ischaemic encephalopathy secondary to intrapartum hypoxia

A 2-day-old neonate, Laura Angela Willmett, died from hypoxic-ischaemic encephalopathy following intrapartum hypoxia. She was born by emergency caesarean section after a planned vaginal birth after caesarean (VBAC) at a …

obstetricsmidwiferydiagnosticcommunicationparacetamol/codeine
SA2019-12-20

Coroner's Finding: MORGAN Martina

60y · Female·neck compression by ligature strangulation

Martina Morgan, aged 60, died from ligature strangulation by her own leggings while in police custody at Sturt Police Station in March 2015. She was significantly intoxicated (BAC 0.23%) and taking benzodiazepines when a…

diagnosticcommunicationalcohol
VICcommunity2026-04-15

Finding into death of LX

31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)

A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …

addiction medicinepsychiatrymedicationsystemmethadone
NSWhospital2021-10-22

Inquest into the death of Ivan Goolagong

68y · Male·Metastatic Pancreatic Adenocarcinoma

…te Unit in July 2017, five months after undergoing a Whipple procedure. The coroner found that although his pain management was adequate, he did not receive timely or adequate non-medical, psychosocial palliative care, a…

oncologypalliative caresystemcommunicationamylase
QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

Teresa Bradford, aged 40, was killed by her husband David Bradford in a premeditated domestic homicide at their Pimpama home on 31 January 2017, followed by his suicide. She died from head injuries inflicted with an axe.…

general practicepsychiatrycommunicationsystemwarfarin

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