Coronial
WA2019-08-20

Inquest into the Death of Judy Sonia BOLTON

44y · Female·acute myocardial infarction due to coronary thrombosis

…'s Prison in Western Australia. She had multiple cardiovascular risk factors: Aboriginal status, obesity, smoking, hypertension, and dyslipidemia (detected late). Blood pressure monitoring was inadequate, with rapid de-…

cardiologyemergency medicinediagnosticsystemmetoprolol
TAS2022-11-30

Coroner's Finding: Gurr, Phillip Leslie

54y · Male·Acute severe trauma sustained in a motor vehicle crash, including transected tho…

…t 3 am daily, had vehicle heater on), alcohol consumption (blood alcohol 0.024 g/100mL), distraction from smoking/drinking while driving, a prolonged cough he had suffered for 8 weeks, or an undiagnosed cardiac event (h…

jim beam bourbon and cola
VICmental health2024-02-27

Finding into death of Sidarthan Gajaharan

26y · Male·Craniocervical injuries following a train collision (pedestrian)

… patchy medication adherence (clozapine) contributed to ongoing psychotic symptoms and suicidal ideation; smoking affected clozapine metabolism and blood levels; monitoring of medication compliance needed strengthening;…

psychiatryrehabilitation medicinecommunicationdelayclozapine
QLD2019-12-05

Harrison, Steven Leslie

61y · Male·Coronary atherosclerosis

…Wolston Correctional Centre. He had multiple cardiovascular risk factors including Type 2 diabetes, heavy smoking history, and intravenous drug use. CT scans in 2013 and 2015 revealed severe abdominal aortic calcificati…

cardiologygeneral practicediagnosticsystemmetformin
WAhome2004-11-09

Inquest into the Death of Marlene Faye Ware

56y · Female·Cardiac Failure Secondary to Atherosclerotic Heart Disease, Systemic Hypertensio…

Marlene Faye Ware, a 56-year-old Aboriginal woman serving home detention for traffic offences, collapsed suddenly at home on 24 November 2002 and died in the Emergency Department of Royal Perth Hospital. She had Type II …

general practiceemergency medicine
NT2002-08-13

Inquest into the death of Graham Murrurkuwuy

49y · Male·cor pulmonale and chronic bronchitis and emphysema

…and chronic bronchitis/emphysema while imprisoned at Darwin Correctional Centre. He had a long history of smoking and substance abuse. Medical staff were not immediately summoned despite prison officers observing deteri…

general practiceemergency medicinedelay
NThospital2014-02-13

Inquest into the death of Peter Clarke

55y · Male·bronchopneumonia complicating metastatic carcinoma of the right lung, with emphy…

Peter Alexander Clarke, a 55-year-old Aboriginal man and serving prisoner, died of bronchopneumonia complicating metastatic lung carcinoma with emphysema, coronary atherosclerosis and chronic pancreatitis. He presented t…

emergency medicineintensive carediagnostic
WAhospital2020-03-20

Inquest into the Death of Norman Alexander HAZELGROVE

73y · Male·metastatic carcinoma of the lung with palliation

Norman Hazelgrove, a 73-year-old prisoner, died from metastatic lung carcinoma in September 2017. Early in his imprisonment (2013), a chest X-ray showed COPD but this diagnosis was not formally documented or managed desp…

respiratory medicineoncologydiagnosticsystemantihypertensive medication
WA2019-07-11

Inquest into the Death of Annabel NICOL

50y · Female·ligature compression of the neck (hanging)

…tified systemic failures: the Crisis Care Unit (CCU) was non-therapeutic and highly restrictive, limiting smoking and fresh air access which exacerbated her distress and made her reluctant to disclose ongoing suicidal t…

psychiatrycorrectional healthsystemdelaymirtazapine
WAhospital2021-08-06

Inquest into the Death of Lajos SZABO

64y · Male·metastatic adenocarcinoma of the lung (palliated)

Lajos Szabo, a 64-year-old prisoner, died from metastatic adenocarcinoma of the lung with brain metastases. He presented to prison medical services in November 2018 with neck swelling and fever, was promptly investigated…

general practicerespiratory medicine
VICaged care2013-11-21

Finding into death of Ivo John Martinov

58y · Male·Unascertained causes

…o undetected cardiovascular disease, as the patient had multiple cardiac risk factors (diabetes, obesity, smoking). Clinicians should not over-interpret elevated post-mortem clozapine levels without autopsy confirmation…

psychiatrygeneral practicesystemclozapine
NSWhome2025-07-30

Inquest into the death of Hilary Gordon-Squire

65y · Male·Pneumonia, due to chronic lung disease with atherosclerotic cardiovascular disea…

A 65-year-old man with severe chronic lung disease, COPD, and coronary artery disease died at home. Evidence suggests he deliberately ingested benzodiazepines and possibly other substances in a self-harm attempt. However…

forensic medicinegeneral practicesystemdelaybenzodiazepines
VIChospital2015-12-09

Finding into death of Benjamin David Johnston

36y · Male·Global hypoxic brain injury due to hanging

…amin Johnston, a 36-year-old male, died by hanging after six weeks of varenicline (Champix) treatment for smoking cessation. Two weeks before death, his partner noted significant behavioral changes: withdrawal, irritabi…

general practicepsychiatryvarenicline
SAhospital2013-04-24

Coroner's Finding: HOLLONDS Andrew David

37y · Male·compression of the neck consistent with hanging

Andrew David Hollonds, a 37-year-old man with personality disorder, substance misuse, and recent psychosis, presented to hospital after a suicide attempt (temazepam overdose) following job loss. He explicitly threatened …

psychiatryemergency medicinesystemcommunicationtemazepam
WA2025-06-12

Inquest into the Death of Sam Phillip Chisholm LYNCH

27y · Male·effects of fire

…on grossly inadequate and the death preventable had Hakea possessed fire suppression systems, implemented smoking bans, maintained equipment properly, and had adequate staffing. Systemic failures across multiple domains…

systemcommunicationdiazepam
VIChospital2021-10-29

Finding into death of John Crabtree

69y · Male·Myocardial infarction secondary to coronary artery atherosclerosis in the settin…

Mr Crabtree, a 69-year-old man with intellectual disability, COPD, emphysema and heavy smoking history, presented to the ED with respiratory distress on 26 May 2016. He was diagnosed with infective ex…

emergency medicinegeneral practicediagnosticdelayamoxicillin/clavulanate
QLDhospital2006-08-10

Casey, Lenard John

39y · Male·Coronary thrombosis caused by coronary atherosclerosis

…reventable given his long-standing refusal of surgery, non-compliance with medication, heavy alcohol use, smoking, and lack of lifestyle changes, despite numerous prior admissions and repeated medical advice over many y…

cardiologyemergency medicinecommunicationmorphine
WAmental health2011-04-21

Inquest into the Death of Barnes

50y · Female·acute heart failure in association with acute on chronic obstructive airways dis…

Donna Lillian Barnes, a 50-year-old woman with chronic schizophrenia and multiple physical comorbidities including morbid obesity, asthma, and poor mobility, died of acute heart failure associated with acute-on-chronic o…

psychiatrygeneral medicinecommunicationsystemantibiotics
WAmental health- 11 April 2014

Inquest into the Death of Robert Kenneth SCOTT

28y · Male·ligature compression of the neck (hanging)

Robert Kenneth Scott, a 28-year-old man with schizophrenia, died by hanging on 22 May 2008 after absconding from Graylands Hospital where he was an involuntary patient. He was last seen at 4:30pm on an open ward with 60-…

psychiatrydelayclozapine
SA2011-09-19

Coroner's Finding: RIGNEY Vincent Norman

35y · Male·ischaemic heart disease due to coronary atherosclerosis

A 35-year-old Aboriginal man died of ischaemic heart disease due to coronary atherosclerosis whilst in prison custody. He presented with chest pain and arm tingling at 6:20am but received only Panadol and Mylanta from no…

cardiologyemergency medicinediagnosticdelayparacetamol
156715

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