Inquest into the death of Keith Titmuss

20y · Male·exertional heat stroke

…rofessional rugby league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest aerobic fitness of his cohort (Yo-Yo…

Non-inquest findings into the death of Mr K

81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…

…patient safety in high-risk cases. The private hospital lacked oxygen administration guidelines and staff training in advanced respiratory management. Early recognition of deterioration and escalation to the public hospi…

Hatzidimitriadis, Georgina

51y · Female·drowning

…before extrication. While guides were appropriately qualified and equipment was adequate, the operator's procedures failed to account for participants with limited English proficiency, inadequate group control, and lack …

Coroner's Finding: DALY Michael Barry

53y · Male·Burns to 75% of body surface area and severe lower airway inhalation injury

…ce and custody staff were unaware of his detention status due to failures in communication and inadequate training regarding MHA protocols. Glenside staff received misleading information that he would remain in custody u…

Finding into death of Kara Lennah Compton

1y · Female·acute on chronic respiratory failure

…th conditions made survival unlikely even with optimal intervention. Clinical lessons include: inadequate training in intraosseous access for paediatric trauma when IV access fails; the need for direct communication betw…

Inquest into the Death of Maureen MANDIJARRA

44y · Female·unascertained (consistent with Streptococcus dysgalactiae and Staphylococcus aur…

…eriously unwell and detained her in Cell 4 overnight. Cell checks were inadequate and non-compliant with procedures. She was found unresponsive at 4:29 AM and despite resuscitation attempts, died shortly after. The cause…

Non-inquest findings into the death of Mr B.

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

… intended 10% phenol concentration. Key clinical lessons include: (1) radiologists performing unfamiliar procedures must actively seek detailed knowledge from literature and colleagues, not assume medication is pre-prepa…

Inquiry into the Fire at Springwood NSW 17 October 2013? And the Fire at Mt Victoria NSW 17 October 2013

…te vegetation management programs. Endeavour Energy's vegetation management contractors lacked sufficient training and equipment, particularly a sounding hammer, to properly identify hazard trees. Additionally, there was…

Finding into death of Silvie Marion Burton

89y · Female·Acute upper airway obstruction by food bolus

…delay before attempting to relieve the obstruction, and a further delay (approximately 4 minutes) before emergency services were contacted. First aid response did not align with St John Ambulance Victoria guidelines, wh…

Finding into death of Steven John Bamblett

29y · Male·Hanging

Steven John Bamblett, a 29-year-old Aboriginal man, died by hanging on 14 January 2020 following service of a Family Violence Intervention Order application. He had a documented history of untreated mental illness with f…

MUHAMMAD, Mahsan

48y · Male·Undetermined; most likely drowning at sea

…ls. The Master (Mr Kevin Lee) supervised the work but failed to ensure compliance with documented safety procedures. A comprehensive search with 94% probability of detection found no body. The coroner found the death lik…

Inquest into the death of Liam WOLF

19y · Male·unexpected arrhythmogenic event leading to a fall from height, blunt force head …

…year-old Australian Army recruit, died after collapsing on an obstacle course at Kapooka during the final training exercise. He experienced a sudden unexpected cardiac arrhythmia while climbing a ladder in an underground…

Inquest into the death of Hugh David LISLE

24y · Male·cardio-respiratory arrest due to multi-drug toxicity

…rug-seeking behaviour); strict medication administration oversight; and maintaining advanced life support training for all staff in high-risk psychiatric facilities. While psychiatrist-led care was appropriate and resusc…

Jacobs, Roy Rodney

48y · Male·Coronary artery disease precipitating acute myocardial infarction resulting in c…

…l handover between doctors; and nursing staff not understanding Q-ADDS escalation triggers despite annual training. On final admission, high Q-ADDS scores overnight were not acted upon—no medical review occurred, observa…

Inquest into the Death of William Frederick ANDERSON

53y · Male·intracerebral haemorrhage

… man aged 53, suffered a catastrophic intracerebral haemorrhage while imprisoned and died despite timely emergency response. Multiple delays occurred: 25 minutes before the cell was opened, 20 minutes before ambulance w…

Inquest into the death of Sony William Tran-Bui

33y · Male·complications of acute peritonitis caused by rupture of a duodenal ulcer

…no Justice Health staff attended the cell alarm. Recommendations address accessible HPNF placement, staff training on observation requirements, direct communication with inmates, and Justice Health staff accompaniment to…

Inquest into the death of Brandoli POU

29y · Male·severe chest injuries sustained when struck by a magnetic lifter attached to an …

…onset and did not visually track the lifter during the incident, he adequately received formal accredited training in crane operation. The death resulted from crane operation not complying with established safety procedu…

Inquest into the death of Nathan REYNOLDS

36y · Male·bronchial asthma

…om bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease management. On the night of his death, correctional officers took 11 minute…

Finding into death of Audrey Florence Eleanor Ebbage

1y · Female·Dilated cardiomyopathy

An 18-month-old girl died from dilated cardiomyopathy masquerading as croup. While initially misdiagnosed as croup was reasonable, the failure to reassess when clinical improvement did not occur was critical. Key failure…

Inquest into the death of Pamuk RONA

53y · Female·unascertained natural causes

…onia in psychiatric settings. Post-incident, the health service implemented improvements including formal training on catatonia recognition and escalation procedures, formalised lorazepam availability for parenteral admi…