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VIC2021-05-21

Finding into death of William Maxwell

53y · Male·Hanging

William Maxwell, a 53-year-old corrections officer, died by hanging on 27 March 2018. The inquest examined whether workplace bullying contributed to his death. Maxwell had changed his statement about a colleague's miscon…

VIChome2021-05-20

Finding into death of Brodie Moran

8y · Male·Suffocation

Brodie Moran, an 8-year-old boy, died by suffocation at the hands of his mother, Ms Finch, on 8 March 2018. Ms Finch had a history of depression and anxiety, experiencing significant deterioration in mental health follow…

general practicepsychiatrysystemvenlafaxine
VIChospital2021-05-18

Finding into death of David John Campbell

59y · Male·Intracerebral haemorrhage

A 59-year-old man imprisoned at Hopkins Correctional Centre collapsed on 16 July 2019 with a left thalamic intracerebral haemorrhage with intraventricular rupture. He was transferred to Royal Melbourne Hospital where an …

neurosurgeryintensive carelevetiracetam
VIChome2021-05-15

Finding into death of Ms ZT

27y · Female·Multiple sharp force injuries

Ms ZT, a 27-year-old Lebanese woman, was murdered by her husband Mr BR on 17 June 2016 through multiple sharp force injuries. The coroner's investigation revealed a prolonged pattern of severe domestic violence, physical…

communicationsystem
VIChospital2021-05-10

Finding into death of Karim Aarras

45y · Male·Blood loss due to multiple self-inflicted incised injuries

Karim Aarras, a 45-year-old man with longstanding mental health issues, chronic pain, and substance use disorder (methamphetamine), presented to police in a severely agitated state following self-harm with a broken bottl…

psychiatryemergency medicinemethamphetamine
VICcommunity2021-05-07

Finding into death of Michael Gerald Anthony

26y · Male·Hypoxic ischaemic encephalopathy in the context of neck compression

A 26-year-old man with longstanding mental health issues and substance use died from hypoxic ischaemic encephalopathy caused by neck compression during a physical altercation with his brother at a family event. Mr Anthon…

forensic medicineintensive carealcohol
VIChome2021-05-07

Finding into death of Arthur John Smith

91y · Male·Gunshot wound to the head

Arthur Smith, 91, fatally shot his wife of 68 years before taking his own life. He had recently undergone cardiac surgery and expressed concerns about losing independence and being forced into care. The couple faced fina…

cardiothoracic surgeryrehabilitation medicine
VIChome2021-05-07

Finding into death of Gwen Adeline Smith

91y · Female·Gunshot wound to the head

Gwen Adeline Smith, 91, was fatally shot by her husband Arthur Smith on 25 July 2018 at their home in Parwan, Victoria. Mr Smith then died by suicide. The couple had been experiencing significant stressors including fina…

general practicecardiothoracic surgerydoxepin
VIC2021-05-07

Finding into death of Joanne Finch

42y · Female·Neck compression due to self-suspension

Joanne Finch, a 42-year-old woman remanded in custody on charges related to her son's death, died by hanging in her cell at Dame Phyllis Frost Centre on 24 July 2018. She had chronic suicidal ideation with periods of acu…

psychiatrypsychologyolanzapine
VIChome2021-05-05

Finding into death of Aisha Devi Beck

39y · Female·Gunshot wound to the head

A 39-year-old woman with brief psychotic disorder experiencing suicidal and homicidal ideation killed her 4-year-old daughter and herself. She had been diagnosed with psychosis in 2015, treated with olanzapine, and disch…

psychiatrygeneral practicecommunicationsystemolanzapine
VIChome2021-05-05

Finding into death of Aziza Beck

3y · Female·gunshot wound to the head

A 3-year-old girl was killed by her mother, who was experiencing a severe psychotic episode with suicidal and homicidal ideation. The mother had a history of Brief Psychotic Disorder (diagnosed 2015), was on olanzapine 1…

psychiatrygeneral practicecommunicationsystemolanzapine
VIChospital2021-05-01

Finding into death of Sharni Dee Connolly

37y · Female·Multiple drug toxicity

Sharni Dee Connolly, a 37-year-old registered nurse turned naturopath, died from multiple drug toxicity following a hamstring injury requiring opioid analgesia. She was prescribed excessive quantities of pregabalin (105m…

general practiceemergency medicinemedicationcommunicationtapentadol
VICcommunity2021-04-30

Finding into death of Kent Thomas

68y · Male·Hanging

Kent Thomas, aged 68, died by hanging in December 2018. He had experienced chronic tinnitus since 2013 which severely impacted his mental health and quality of life. Despite referral to mental health services and a reaso…

general practicepsychiatrydiagnosticdelayclonazepam
VIChospital2021-04-30

Finding into death of Valerie Margaret Fraser

94y · Female·Complications of metastatic lobular carcinoma of the breast in a woman with deme…

A 94-year-old woman with advanced dementia and metastatic breast cancer died from complications of her malignancy. She presented repeatedly with vomiting due to duodenal obstruction from metastatic tumour, but this was n…

general medicinegastroenterologycommunicationdiagnostictamoxifen
VIC2021-04-29

Finding into death of Spiros Boursinos

45y · Male·coronary artery disease and mechanical asphyxia in a man using cocaine

A 45-year-old man with a history of drug-induced psychosis, cocaine use, and underlying coronary artery disease died in police custody following physical restraint at a licensed bar. After consuming cocaine, he experienc…

emergency medicinepsychiatrycocaine
VIC2021-04-28

Finding into death of Mohamed Omar

30y · Male·neck compression

Mohamed Omar, a 30-year-old man with schizophrenia, died in Melbourne Assessment Prison on 25 June 2017 from neck compression while on remand. He had a history of command auditory hallucinations instructing self-harm, re…

psychiatrycorrectional healthflupenthixol depot injection
VIChospital2021-04-25

Finding into death of Gary Edward Holmes

64y · Male·Hypostatic bronchopneumonia complicating end stage Parkinson's disease

Gary Edward Holmes, 64, died from hypostatic bronchopneumonia complicating end-stage Parkinson's disease while receiving palliative care at Colac Hospital. He was a profoundly disabled man (deaf and blind from childhood)…

general practicepalliative caresystemcommunicationmorphine
VICaged care2021-04-23

Finding into death of Josephine Helen Clarke

69y · Female·Complications of a subdural haemorrhage (palliated) sustained in a fall

Josephine Helen Clarke, age 69, died from complications of a subdural haemorrhage sustained in a fall at Kingston Centre rehabilitation facility on 11 September 2018. Mrs Clarke had been recovering from a subarachnoid ha…

geriatric medicineneurosurgerysystemcommunication
VICcommunity2021-04-16

Finding into death of Barbara Dawson

20y · Female·haemorrhage from lacerated throat

Barbara Ellen Dawson, aged 20, disappeared on 29 October 1980 and was found dead three days later with a lacerated throat in Kororoit Creek, Altona North, Victoria. A coronial re-investigation utilising modern DNA profil…

forensic medicine
VICcommunity2021-04-14

Finding into death of JJ

70y · Male·Hanging

A 60-year-old man with recent pituitary surgery developed persistent fatigue and depressive symptoms. Despite normal cortisol levels, he remained convinced his symptoms were due to hormonal deficiency rather than depress…

psychiatryendocrinologycommunicationsystemvenlafaxine

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