Coronial

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SAhome2017-07-25

Coroner's Finding: MCKENZIE Deborah Francis

22y · Female·compression of the neck consistent with hanging

22-year-old Deborah McKenzie, an Aboriginal woman, died by hanging on 13 March 2013 after a complex sequence of failures in mental health care and police procedures. She had reported her partner Shane Woods to police for…

general practiceemergency medicinediagnosticproceduralparacetamol
VIC2024-06-19

Finding into death of X Y

17y · Female·Neck compression by hanging (suicide)

XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as …

paediatricspsychiatrycommunicationsystemvenlafaxine
VIChospitalPodcast2026-02-20

Finding into death of James Harilaos Tsindos

17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis

James Tsindos, a 17-year-old with known nut allergy and mild asthma, experienced anaphylaxis after inadvertently ingesting cashews in a vegan restaurant meal on 27 May 2021. Ambulance paramedics administered two doses of…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline (epinephrine) intramuscular
QLD2006-09-27

Mulrunji

36y · Male·intra-abdominal haemorrhage due to rupture of liver and portal vein

Mulrunji (Cameron Francis Doomadgee), a 36-year-old Aboriginal man, died from intra-abdominal haemorrhage due to liver rupture following an encounter with Senior Sergeant Christopher Hurley at Palm Island Police Station …

forensic medicineemergency medicinediagnosticprocedural
SA2020-11-26

Coroner's Finding: KEN Kenneth Ngalatji

68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…

A 68-year-old Aboriginal man died by hanging in his cell at Yatala Labour Prison on 16 April 2015 while experiencing acute myocardial infarction. He was transferred to Yatala for urgent psychiatric assessment following t…

psychiatrycardiologydiagnosticcommunicationolanzapine
NSWprison2021-11-19

Inquest into the death of Danny Whitton

25y · Male·Multiple organ failure due to acute paracetamol poisoning

Danny Whitton, a 25-year-old Aboriginal prisoner at Junee Correctional Centre, died from acute paracetamol toxicity causing multi-organ failure. He presented to the prison medical clinic on 5 November 2015 with vomiting …

emergency medicinetoxicologydiagnosticcommunicationparacetamol
QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

Teresa Bradford, aged 40, was killed by her husband David Bradford in a premeditated domestic homicide at their Pimpama home on 31 January 2017, followed by his suicide. She died from head injuries inflicted with an axe.…

general practicepsychiatrycommunicationsystemwarfarin
SAaged care2026-02-12

Coroner's Finding: D Angelo, Adelina

88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…

…missed-diagnosed stroke based on asymmetric tone, and mistakenly believed the patient was not for active treatment, delaying hospital transfer by 18 hours. The coroner found dehydration preventable through: recognition …

general practicegeriatric medicinediagnosticcommunicationfurosemide

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