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QLDhome2022-07-12

Jack - Non-inquest findings

41y · Male·Stab wound to the chest

Jack, a 41-year-old man with extensive history of domestic violence perpetration across multiple relationships, died from a stab wound to the chest inflicted by his partner Sally during a domestic disturbance. Sally had …

forensic medicinecorrectional healthcommunicationsystemmethamphetamine
VICcommunity2022-07-12

Finding into death of Timothy Dale Fehring

15y · Male·Hypoxic-ischaemic encephalopathy complicating cardiac arrest in the setting of b…

Timothy Fehring, 15-year-old on a school excursion to Europe, died of hypoxic-ischaemic encephalopathy from cardiac arrest in the setting of bronchopneumonia and gastroenteritis. He developed gastroenteritis symptoms on …

paediatricsemergency medicinediagnosticcommunicationparacetamol
VIC2022-07-11

Finding into death of Mladen Jovanoski

57y · Male·Consequences of multiple injuries (from fall from elevated walkway)

Mladen Jovanoski, a 57-year-old remand prisoner, died from head injuries sustained after falling from a prison walkway on 11 April 2018. He had suspected metastatic thyroid cancer requiring urgent biopsy at a tertiary ho…

endocrinologyoncologysystemcommunication
QLDhospital2022-07-08

R - Non-inquest findings

0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…

A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…

anaesthesiaintensive carediagnosticproceduralpropofol
SAmental health2022-07-08

Coroner's Finding: Cardwell, Phillip David

53y · Male·lung abscess with empyema

A 53-year-old man with schizophrenia died from lung abscess with empyema while an involuntary inpatient at a mental health facility. He had been readmitted with a respiratory infection and was treated with intravenous an…

psychiatryemergency medicinedelayclozapine
QLDhospital2022-07-07

S - Non-inquest findings

2y · Male·Crush chest injuries

A two-year-old boy died from crush chest injuries after a heavy homemade hallway table (approximately 70kg, made from a railway sleeper) toppled onto him while he was playing at home. He was found unresponsive by his par…

emergency medicinepaediatricssystem
TAScommunity2022-07-06

Coroner's Finding: McKillop, John Andrew

58y · Male·drowning due to loss of consciousness from acute coronary event (unstable plaque…

A 58-year-old man with a 5-year history of cardiology follow-up died during a recreational canoeing expedition. Despite previous cardiology assessment detecting no ischaemic heart disease, autopsy revealed severe ischaem…

cardiologyemergency medicine
VICaged care2022-07-06

Finding into death of Catherine Ann Collier

51y · Female·Aspiration in the setting of end stage down syndrome

Catherine Ann Collier, a 51-year-old woman with Down syndrome, end-stage hydrocephalus, and severe dysphagia, died from aspiration pneumonia following a choking episode while eating. The Disability Services Commissioner …

neurologyspeech pathologysystemcommunicationsodium valproate
NSW2022-07-06

Inquest into the death of Kevin BUGMY

57y · Male·Severe coronary artery disease. It is likely that Kevin's use of inhalants in cu…

Kevin Bugmy, a 57-year-old Aboriginal man, died of severe coronary artery disease while in custody at Cessnock Correctional Centre. The coroner found the care received for his chronic inhalant use disorder was grossly in…

cardiologygeneral practicediagnosticcommunicationacetone
WA2022-07-06

Inquest into the Death of Paul Stephen KEATING

60y · Male·atherosclerotic heart disease (cardiac arrhythmia secondary to severe long-stand…

Paul Stephen Keating, a 60-year-old man with severe atherosclerotic heart disease, died from cardiac arrhythmia while incarcerated in Casuarina Prison, Western Australia. He had significant coronary artery disease diagno…

cardiologycorrectional healthamiodarone
NSWcommunity2022-07-05

Inquest into the deaths of Darren WALLACE and T B D

Male·Darren Wallace: single gunshot wound to right side of neck. TBD: two self-inflic…

Two deaths occurred on 9 December 2015 in a tragic incident connected to a dispute within the Rebels Outlaw Motorcycle Gang. TBD, a 31-year-old former ADF member with severe post-traumatic stress disorder (PTSD), alcohol…

psychiatryemergency medicinesystemdelaysertraline
TAScommunity2022-07-04

Coroner's Finding: Leighton, Garth Mcdonald

58y · Male·chest and abdominal injuries sustained in motor vehicle collision

A 58-year-old experienced motorcycle rider died from massive chest and abdominal injuries after losing control on a rural curve and colliding with an oncoming vehicle. He was initially conscious with three doctors presen…

emergency medicinesurgerysystemdelay
TAShome2022-07-04

Coroner's Finding: Wallace., Vivienne Lorraine

73y · Female·atherosclerotic and hypertensive coronary vascular disease

Ms Wallace, a 73-year-old woman with hypertension and other comorbidities, developed atrial fibrillation during orthopaedic surgery for a fibula fracture. She was discharged on flecainide 50mg daily, metoprolol, and riva…

cardiologyorthopaedic surgeryflecainide
TAShospital2022-07-01

Coroner's Finding: CL de-identified

33y · Female·hanging

A 33-year-old woman with major depressive disorder and a history of suicide attempts died by hanging five days after discharge from hospital following a carbon monoxide poisoning attempt. The coroner found that discharge…

psychiatryemergency medicinediagnosticcommunicationsertraline
NSWcommunity2022-07-01

Inquest into the death of Mark MURPHY

49y · Male·Global cerebral hypoxia due to cardiac arrest and drowning, with bilateral bronc…

Mark Murphy, an experienced diver with 657 logged dives, died during an occupational diving course when his full face mask became accidentally dislodged underwater, resulting in sudden cold-water exposure. This triggered…

diving medicineemergency medicinesystemcommunication
ACThospital2022-06-30

Inquest into death of DEAN CHRISTOPHER BRICE (No. 2)

25y · Male·Cardiorespiratory arrest due to aspiration pneumonia and hypoxic-ischaemic encep…

Dean Brice, aged 25, died from accidental multiple drug toxicity (methamphetamine and GHB) causing cardiorespiratory arrest, aspiration pneumonia and hypoxic-ischaemic encephalopathy. He was subject to a Psychiatric Trea…

psychiatryemergency medicinemethamphetamine
TAShome2022-06-30

Coroner's Finding: MX De-identified

5y · Unknown·Undetermined Sudden Infant Death (USID)

A 5-month-old infant died suddenly while co-sleeping with his mother on an adult bed with adult bedding. Post-mortem examination revealed undetermined sudden infant death (USID) with reactive splenic changes consistent w…

pathologypaediatrics
QLDhome2022-06-30

Tabuai, James Daniel

0y · Male·Acute traumatic head injury (non-accidental)

A 7-month-old child died from acute traumatic head injury sustained from non-accidental blunt force. Clinical lessons include: medical staff should strongly reinforce urgent referrals (the child had a critical GP referra…

general practiceemergency medicinecommunicationdelay
QLDcommunity2022-06-29

Clarke, Hannah Ashlie; Baxter, Aaliyah Anne; Baxter, Laianah Grace; Baxter, Trey Rowan Charles; Baxter, Rowan Charles

Mixed·Hannah Clarke: multi-organ failure due to effects of fire; Aaliyah, Laianah and …

Hannah Clarke, aged 33, and her three children (ages 6, 4, and 3) were killed by her estranged husband Rowan Baxter on 19 February 2020 in Camp Hill, Queensland. Baxter forced his way into Hannah's car, doused the family…

emergency medicineparamedicinediagnosticcommunication
VICcommunity2022-06-24

Finding into death of H YO

44y · Male·Heroin toxicity

A 44-year-old man with a 24-year history of opioid addiction died from heroin toxicity two days after release from prison on a Community Corrections Order. He had been on opioid replacement therapy (Suboxone) but discont…

addiction medicinecorrectional healthsystemdelayheroin

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