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NSW2022-03-07

Inquest into the death of Ali Kizildag

47y · Male·Acute opioid (Heroin) toxicity

Ali Kizildag, 47, died from acute opioid (heroin) toxicity while in custody at Dawn De Loas Correctional Centre on 11 September 2018. He was found unresponsive in his cell after failing to return from a medical appointme…

general practiceforensic medicineheroin
VIC2022-03-03

Finding into death of Andrew William Staker

55y · Male·Pulmonary thromboembolism secondary to deep thrombosis, with WHO Class 3 obesity…

A 55-year-old man died in prison from pulmonary thromboembolism secondary to deep vein thrombosis, with WHO Class 3 obesity as a contributing factor. He presented with acute breathing difficulties and collapsed despite i…

forensic medicineemergency medicinefluoxetine
WAhospital2022-03-03

Inquest into Death of Van Tho NGUYEN

59y · Male·metastatic lung cancer, with palliation

Van Tho Nguyen, a 59-year-old remand prisoner with metastatic lung cancer, died of natural causes in a private hospital palliative care setting. He had been a lifelong smoker who developed advanced adenocarcinoma with bo…

oncologypalliative caresystemcommunicationchemotherapy agents
TAScommunity2022-03-01

Coroner's Finding: Gray, Alan Maurice

77y · Male·traumatic closed head injury due to a fall from standing

Alan Maurice Gray, 77, suffered a fall at a service station on 16 September 2020, hitting his head. He called for an ambulance at 7:54pm but paramedics did not arrive until 12:09am (4 hours 15 minutes delay). CT imaging …

emergency medicineneurosurgerydiagnosticsystem
TAShospital2022-02-28

Coroner's Finding: Hassanloo, Saeed

27y · Male·traumatic injuries and/or drowning from jumping from Tasman Bridge

A 27-year-old Iranian asylum seeker died by suicide after jumping from Tasman Bridge. He had a complex psychiatric history including depression, anxiety, and adjustment disorder, with multiple self-harm episodes. His sec…

psychiatryemergency medicine
VIChospital2022-02-28

Finding into death of H YR

77y · Female·Haemoperitoneum following cholecystectomy

A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication bu…

general surgeryintensive carediagnosticdelaywarfarin
VIChospital2022-02-25

Finding into death of Joseph Cardona

49y · Male·haemopericardium secondary to ruptured aortic dissection

Joseph Cardona, 49, died from ruptured aortic dissection with haemopericardium. He presented to the ED twice within 24 hours with severe central chest pain radiating to jaw, neck, and back, associated with hypertension. …

emergency medicinecardiologydiagnosticcommunicationoxycodone
NSWhospital2022-02-25

Inquest into the death of Carley METCALFE

41y · Female·unable to determine

Carley Metcalfe, aged 41, was found deceased in the Brunswick River in November 2017, three weeks after disappearing. She had presented to Lismore Base Hospital on 1-2 November 2017 with acute psychosis related to schizo…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
WAmental health2022-02-25

Inquest into the Death of Jordan James WILLIAMS

20y · Male·head and neck injuries sustained when struck by train

Jordan James Williams, 20, died after being struck by a train following two absconsions from Kalgoorlie Health Campus mental health unit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Crit…

psychiatryemergency medicinesupervisioncommunicationolanzapine
TAS2022-02-24

Coroner's Finding: Scott, Paul Stephen

61y · Male·asphyxial death due to hanging

Paul Stephen Scott, aged 61, died by hanging while on leave from psychiatric inpatient care. He had been admitted to Spencer Clinic on 11 January 2018 with suicidal ideation and complex psychiatric presentation. Despite …

psychiatrygeneral practicesystemcommunicationvenlafaxine
VICcommunity2022-02-24

Finding into death of Peter Trimbos

52y · Male·Head injuries

Peter Trimbos, a 52-year-old lawyer, died by suicide following overwhelming psychological distress from multiple stressors: the deaths of his parents and father-in-law from COVID-19, and involvement in a highly publicise…

general practicepsychiatrysystemdelay
TAShome2022-02-23

Coroner's Finding: BR - deidentified

0y · Female·Undetermined - coroner unable to determine exact cause; unsafe sleeping environm…

A 5-month-old infant died suddenly in a co-sleeping environment with adults and a toddler in a queen-sized bed with adult bedding. Autopsy revealed no definitive cause but identified significant risk factors: unsafe slee…

paediatricsneonatologysystem
VIChome2022-02-23

Finding into death of Mark Edward Elliott

58y · Male·Shotgun wound to the neck

Mark Edward Elliott, a 58-year-old prominent lawyer, died by suicide on 13 February 2020 following a shotgun wound to the neck. He was experiencing significant occupational and legal stress related to protracted proceedi…

general practiceemergency medicinediagnosticcommunicationzolpidem
TAScommunity2022-02-22

Coroner's Finding: BL de-identified

47y · Male·Extensive burns sustained in a deliberately set fire

A 47-year-old male died from extensive burns sustained in a deliberately set house fire on 29 November 2020. He had experienced a relationship breakdown and severe depression with suicidal ideation. He presented to hospi…

psychiatryemergency medicine
VIChospital2022-02-22

Finding into death of Matthew Lee Dongelmans

30y · Male·Complications of methylamphetamine toxicity

Matthew Dongelmans, aged 30, died from complications of methylamphetamine toxicity after being arrested for breaching a family violence intervention order. He consumed methylamphetamine prior to arrest, likely in panic w…

emergency medicineintensive caredelaysystemmethamphetamine
TAShome2022-02-18

Coroner's Finding: XY - deidentified

84y · Male·Overdose of prescription morphine (Ordine oral morphine liquid), self-administer…

An 84-year-old man with advanced emphysema, colorectal cancer history, and severe functional decline took an intentional overdose of prescription morphine at home. In the weeks before death, he experienced progressive dy…

general practicerespiratory medicinemorphine
TAShome2022-02-18

Coroner's Finding: FL de-identified

17y · Unknown·hypoxic brain damage from out of hospital cardiac arrest

FL was a 17-year-old with complex medical needs including short bowel syndrome and dependence on total parenteral nutrition (TPN) via central vascular access device. In June 2020, he became severely unwell with deteriora…

paediatric surgerygastroenterologydiagnosticdelay
TAShome2022-02-18

Coroner's Finding: Gardiner, Timmothy Matthew

29y · Male·Gunshot wound to the chest

Timothy Matthew Gardiner, aged 29, died from a gunshot wound to the chest sustained when he accidentally dropped a homemade firearm he was carrying while bending to collect belongings at a friend's unit. The firearm, con…

forensic medicineemergency medicinemethamphetamine
VICcommunity2022-02-18

Finding into death of Roger David Batchelor

57y · Male·Hypoxic ischaemic encephalopathy secondary to prolonged downtime due to upper ai…

A 57-year-old man with intellectual disability and a documented history of choking died from hypoxic ischaemic encephalopathy following airway obstruction by food at a day activities program. Despite having a choking man…

general practicespeech pathologycommunicationsystempantoprazole
NSWcommunity2022-02-18

Inquest into the death of SP

36y · Male·hanging

A 36-year-old man died by hanging on 10 July 2018 after leaving his home in Blacktown, NSW. His partner called Triple Zero after 30 minutes, reporting concern for his welfare and that he was acting strangely, restless, a…

emergency medicineparamedicinecommunicationsystem

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