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VIChospital2025-07-04

Finding into death of Geoffrey David Thorn

62y · Male·urosepsis

Geoffrey Thorn, a 62-year-old man with intellectual disability, Lennox-Gastaut syndrome, and cerebral palsy, died from urosepsis following emergency urological surgery for a kidney stone. He presented to hospital with fe…

emergency medicineurology
SAhospital2025-07-03

Coroner's Finding: Cheesman, Trevor Allan

70y · Male·complications arising from craniofacial resection and orbital exenteration for r…

A 70-year-old man died following complex craniofacial resection and orbital exenteration for right sinonasal adenocarcinoma. Multiple surgical complications occurred including carotid artery injury, cerebral infarction, …

neurosurgeryENT surgerysystemolanzapine
VIChospital2025-06-25

Finding into death of RFV

87y · Male·Consequences of an assault with severe facial fractures

RFV, an 87-year-old man, died from severe facial fractures and traumatic brain injury sustained during an assault by his daughter-in-law. He presented to hospital in critical condition with cardiac arrest, multiple facia…

emergency medicineintensive caresystem
VIChospital2025-06-25

Finding into death of Melanie Louise Gregory

39y · Female·aspiration pneumonia in the setting of general anaesthesia and colonoscopy for i…

A 39-year-old woman with cerebral palsy, dysphagia, and sleep apnoea died from aspiration pneumonia following a colonoscopy performed under sedation for investigation of rectal bleeding. She had known increased aspiratio…

gastroenterologyanaesthesia
SAhospital2025-06-12

Coroner's Finding: Salter, Kathleen Ethel

76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy

A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the com…

general surgeryanaesthesiadiagnosticproceduralapixaban
SAhospital2025-06-11

Coroner's Finding: OHalloran, Emma Louise

48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam

A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…

cardiologygeneral practicesystemcommunicationflecainide
TAShospital2025-06-10

Coroner's Finding: Johnston, Trent Ian

40y · Male·aspiration pneumonitis with acute alcoholic hepatitis, pancreatitis, mixed drug …

Trent Ian Johnston, a 40-year-old man with a history of chronic paranoid schizophrenia, alcohol and substance abuse, died from aspiration pneumonitis complicated by mixed drug toxicity (codeine, morphine, diazepam, parac…

emergency medicineintensive carecodeine
QLDhospital2025-06-02

Non-inquest findings into the death of Mr B.

42y · Male·Multiple organ failure due to iatrogenic phenol overdose due to metastatic pancr…

A 42-year-old man with metastatic pancreatic cancer died from multiple organ failure caused by iatrogenic phenol overdose during a celiac plexus block for pain management. The radiologist administered 40ml of 80% phenol …

radiologyintensive carediagnosticmedicationphenol 80%
NSWhospital2025-05-28

Inquest into the Death of Garry Small

71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …

A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…

emergency medicinegeriatric medicinemedicationdelayceftriaxone
VIChospitalPodcast2025-05-26

Finding into death of Nancy Doreen Hay

99y · Female·Chest injuries in the setting of a tram incident (pedestrian)

A 99-year-old woman with dementia and reduced mobility was struck by a tram while crossing at a roundabout intersection in Essendon, Victoria. She sustained severe chest injuries including bilateral pneumothoraces, haemo…

emergency medicinetrauma surgerysystem
VIChospital2025-05-26

Finding into death of Shawn James Farlech

47y · Male·Pneumonia

Shawn Farlech, a 47-year-old man with acquired brain injury from childhood encephalitis living in specialist disability accommodation, died from pneumonia with sepsis. He presented with fever on 8 April and was initially…

general medicineintensive caresodium valproate
VICaged care2025-05-22

Finding into death of Veronica Lesley Roberts

75y · Female·Ischaemic heart disease in the setting of unstable type 2 diabetes mellitus and …

Veronica Roberts, 75, died from ischaemic heart disease complicated by unstable diabetes and a medication error. On 4 October 2020, her insulin dose was increased to 20 units daily, but due to Electronic Medical Record (…

geriatric medicinegeneral medicinemedicationsystemglargine insulin
SA2025-05-20

Coroner's Finding: Pham, Duy Ngoc

35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…

35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…

emergency medicinegeneral practicedelaycommunicationmethamphetamine
SAhospital2025-05-20

Coroner's Finding: Foster, Stephen John

74y · Male·acute on chronic liver failure complicating common bile duct cholangiocarcinoma …

Stephen John Foster, aged 74, died in hospital from acute on chronic liver failure complicating common bile duct cholangiocarcinoma. He was serving a prison sentence at the time. Initial presentation with jaundice, eleva…

correctional healthsurgery
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…

emergency medicineintensive carediagnosticproceduralhydromorphone
VICmental health2025-05-19

Finding into death of Anna Lee

70y · Female·Asphyxia due to airway obstruction

Anna Lee, a 70-year-old retired psychiatric nurse, died from asphyxia due to airway obstruction while an inpatient in a mental health unit. She was admitted with first-episode mania with psychotic features, triggered by …

psychiatrygeriatric medicinesystemolanzapine
QLDhospital2025-05-01

Non-inquest findings into the death of an Indian citizen

23y · Male·Hypoxic ischaemic encephalopathy due to near-drowning

A 23-year-old Indian citizen drowned at an unpatrolled, hazardous beach on Stradbroke Island after becoming caught in a rip current. He was unable to swim. Despite prompt CPR by lifeguards and paramedics with return of s…

emergency medicineintensive care
VIChospital2025-04-30

Finding into death of Anthony Dzaja

44y · Male·Complications following seizure on a background of acquired epilepsy; acquired b…

Anthony Dzaja, aged 44, died from complications of seizures secondary to acquired brain injury sustained in a 1997 motor vehicle accident. He had progressively deteriorated over several years with worsening epilepsy, cog…

neurologypalliative caremidazolam
VIChospital2025-04-30

Finding into death of Margaret Ann Day

66y · Female·Ischaemic brainstem stroke

Margaret Ann Day, a 66-year-old Specialist Disability Accommodation resident with undifferentiated hereditary ataxia, intellectual disability, and dysphagia, presented to the Emergency Department on 26 November 2024 with…

neurologyemergency medicinelevetiracetam
TAShospital2025-04-29

Coroner's Finding: de-identified OQ

41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…

A 41-year-old woman died from frontal lobe ischaemic infarcts caused by cerebral vasospasm complicating subarachnoid haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days wit…

emergency medicineneurosurgerydiagnosticcommunicationchlorpromazine
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