Coronial
QLDcommunity2007-11-23

Gillies, Bradley James

Male·Physical injuries sustained when concrete truck rolled over at intersection of S…

…d multiple potential contributing factors including vehicle speed, suspension design, driver health (sleep apnoea, low-level cannabis), road camber, and load characteristics. While no single definitive cause was establis…

occupational and environmental healthforensic medicinesystemtrainingcannabis
NThospital2025-03-25

Inquest into the death of Judith Smart

66y · Female·Hypoxic-ischaemic encephalopathy

A 66-year-old woman with COPD, obstructive sleep apnoea, and obesity underwent routine knee surgery at Royal Darwin Hospital. Post-operative care was inadequate. …

anaesthesiaorthopaedic surgerydiagnosticsystemmorphine
VIChospital2003-06-29

Finding into death of Mohammed Tartourssi

3y · Male·unascertained

… symptoms. He was diagnosed with mild symptoms and given prednisolone. That evening, he experienced sudden apnoea and died despite CPR. His cause of death was unascertained at autopsy. Clinical lessons include: (1) the c…

emergency medicinepaediatricsdiagnosticsystemsalbutamol
VIChome2025-07-28

Finding into death of Heather Ida Simone Calgaret

30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…

…she likely experienced respiratory depression from the combination of buprenorphine, obesity, likely sleep apnoea, and quetiapine. Clinical lessons: (1) direct initiation to long-acting injectable buprenorphine without s…

general practiceaddiction medicinemedicationdiagnosticbuprenorphine
QLDcommunity2018-09-11

Giorgio, Pasquale

54y · Male·Ischaemic cardiomyopathy following a period of restraint on a background of morb…

A 54-year-old man with schizophrenia, homelessness, and morbid obesity was arrested for wilful exposure and disorderly conduct. During restraint in the prone position with handcuffs, he struggled for several minutes. Alt…

emergency medicineforensic medicinediagnosticcommunicationflupenthixol
WAhospital2019-11-21

Inquest into the Death of Child SH

5y · Male·aspiration pneumonia with terminal palliative care, in a male child with complex…

A 5-year-old boy with severe congenital myopathy and arthrogryposis died from aspiration pneumonia following terminal palliative care. He had multiple complex medical needs including unsafe swallowing, recurrent respirat…

paediatricsrespiratory medicinesystemmorphine
VIChospital2026-05-22

Finding into death of Stratos Ioannidis

45y · Male·focal coronary artery disease and cardiomegaly

Stratos Ioannidis, age 45, died at Maroondah Hospital on 28 March 2025 from focal coronary artery disease and cardiomegaly during an involuntary psychiatric admission. He presented with acute psychosis from bipolar disor…

psychiatryemergency medicinecommunicationsystemolanzapine
VIC2024-06-21

Finding into death of John Henry Hamilton

67y · Male·Metastatic gastric cancer

John Henry Hamilton, a 67-year-old man with cerebral palsy, intellectual disability, epilepsy and multiple comorbidities, died from metastatic gastric cancer in a palliative care unit. He was diagnosed with metastatic ga…

palliative caregeneral practice
NSW2025-12-08

Inquest into the death of Benjamin Cullen

41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…

Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from P…

neurologyemergency medicinemedicationsystemlevetiracetam
QLDhome2015-01-29

Daw, Lilly Ella - Non-inquest findings

1y · Female·cystic encephalomalacia

…ween obstetric, neonatal and paediatric teams. When Lilly presented with a respiratory tract infection and apnoea, there was no documented awareness of her underlying neurological vulnerability. Clinical lessons: ensure …

obstetricspaediatricscommunicationdelay
VIChome2017-12-04

Finding into death of Leigh Thomas Aiple

31y · Male·Pulmonary thromboembolism

A 31-year-old man with obesity (BMI 40.2) and sleep apnoea underwent extensive cosmetic surgery in Malaysia (liposuction, abdominoplasty, chest lipectomy, and subseq…

plastic and reconstructive surgerygeneral surgerydiagnosticmedicationenoxaparin
VIC2025-05-09

Finding into death of MH J

54y · Female·Unascertained - Definite SUDEP (Sudden Unexpected Nocturnal Death in Epilepsy)

A 54-year-old woman with epilepsy, intellectual disability, schizophrenia, and dementia died suddenly at her supported disability accommodation facility. She was observed asleep and snoring at 9:30pm; by 9:45pm she was u…

neurologypathologycitalopram
TAScommunity2020-03-11

Coroner's Finding: Wood, Glenn Thomas

56y · Male·drowning

Glenn Thomas Wood, aged 56, drowned whilst fishing alone at night from a pontoon in winter conditions. He had a blood alcohol level of 0.188g/100mL, was not wearing a personal flotation device, and could not swim. He fel…

TAShospital2024-10-22

Coroner's Finding: Grimsey, Doreen

91y · Female·congestive cardiac failure

A 91-year-old woman with dementia residing in aged care fell in her room and was transported to hospital for assessment of a suspected pelvic fracture. She deteriorated acutely in the ED with respiratory compromise requi…

geriatric medicineemergency medicine
VIChome2025-01-22

Finding into death of Neil Douglas Heaton

67y · Male·Pneumonia in the setting of aspiration and posterior rib fractures

Neil Douglas Heaton, a 67-year-old man with intellectual disability, dementia, and aspiration risk factors, died from pneumonia complicated by posterior rib fractures of unclear origin. He was found unresponsive at his s…

forensic medicineemergency medicine
VIChospital2023-10-30

Finding into death of Greg John Howarth

62y · Male·Congestive Cardiac Failure in a man with Ischaemic and Hypertensive Heart Diseas…

Greg Howarth, a 62-year-old man incarcerated at Port Phillip Prison, died from congestive cardiac failure precipitated by acute myocardial infarction in the setting of ischaemic and hypertensive heart disease. He had met…

cardiologyoncologyoxycodone
SAhospital2020-11-02

Coroner's Finding: LAMB Dianne Patricia

67y · Female·disseminated adenocarcinoma of the colon

A 67-year-old woman with metastatic colorectal cancer developed multiple cerebral metastases causing marked behavioural changes (irritability, disinhibition, aggression). She was appropriately placed on Mental Health Act…

oncologypsychiatrydexamethasone
VIChospital2011-09-22

Finding into death of Leanne Fiona MacKenzie

48y · Female·abdominal sepsis in a woman with coronary artery disease, post-repair small bowe…

Leanne Mackenzie, 48 years old with Prader-Willi syndrome and intellectual disability, underwent laparotomy for incarcerated incisional hernia on 3 April 2011 at Latrobe Regional Hospital with initial repair but poor pos…

general surgeryintensive care
VICcommunity2021-07-26

Finding into death of Gregory John Bennett

52y · Male·Aspiration Pneumonia

Gregory Bennett, a 52-year-old man with congenital rubella syndrome causing profound disabilities including dysphagia, epilepsy, and spastic quadriparesis, died from aspiration pneumonia. He was living in DHHS-managed ac…

general practiceemergency medicinediazepam
NSW2018-11-15

Inquest into the death of Kenneth Johnstone

79y · Male·Complications associated with metastatic colorectal carcinoma and diabetes melli…

Kenneth Johnstone, a 79-year-old prisoner with extensive comorbidities including metastatic colorectal cancer, diabetes, stage 4 chronic kidney disease, and osteomyelitis, died from cancer complications. He was appropria…

oncologypalliative caremorphine
156711

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