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VIC2021-03-18

Finding into death of Stanley Bruce Weaver

61y · Male·Hanging

Stanley Bruce Weaver, a 61-year-old firefighter with a history of depression and previous suicide attempts, died by hanging at his workplace on 26 August 2019. His wife had reported concerns about medication stockpiling …

psychiatrygeneral practicesystemdiazepam
VIChome2021-03-15

Finding into death of Lina Huynh

44y · Female·Unascertained

Ms Lina Huynh, a 44-year-old woman of Vietnamese descent with limited English, died on 7 September 2017 from unascertained causes following severe head and facial trauma inflicted by her de facto partner during a methamp…

systemcommunicationmethamphetamine
VICcommunity2021-03-10

Finding into death of Casey Evan Cahill

19y · Male·Multiple injuries sustained on a train impact (pedestrian)

Casey Evan Cahill, aged 19, died by suicide on 10 October 2019 when he placed himself in front of a train near Berwick Railway Station. He had a significant history of mental ill health including depression, psychotic sy…

psychiatryaddiction medicinesystemalcohol
VICcommunity2021-03-10

Finding into death of Jack David watson

26y · Male·Plastic bag asphyxia in the setting of a vitiated atmosphere with inert gases

Jack Watson, 26, died by intentional asphyxiation with inert gas on 2 August 2016. He had a long history of mental health issues including ADHD, depression and suicidal ideation. Following acute psychiatric admission to …

psychiatryemergency medicinecommunicationsystemdextroamphetamine
VICcommunity2021-03-03

Finding into death of Michael Brian Sanders

57y · Male·Unascertained causes; presumed suicide by jumping from cliffs

Michael Sanders, a 57-year-old senior educator at a TAFE institution, disappeared on 23 May 2016. He was found standing on a cliff precipice on 24-25 May 2016 and is presumed to have jumped to his death. The coroner iden…

VICcommunity2021-03-01

Finding into death of Scott James Adams

18y · Male·Injuries sustained in a motor vehicle collision (motorcyclist)

Scott Adams, 18, died when his unregistered motorised bicycle was struck by a truck at an intersection. He failed to stop at a stop sign and may not have seen the approaching vehicle. The bicycle, a standard mountain bik…

systemcannabis
VIChospital2021-02-26

Finding into death of Ian Fraser

68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…

Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…

respiratory medicinecardiothoracic surgerymedicationsystemapixaban
VIChospital2021-02-26

Finding into death of MrJ

22y · Male·Drowning

A 22-year-old university student with recent substance use presented to ED following violent behaviour. He had facial trauma with mild head injury and abnormal metabolic parameters. Initial management appropriately prior…

emergency medicinepsychiatrysystemdelayMDMA
VIChome2021-02-25

Finding into death of Rosemary Gibson

62y · Female·Gunshot wounds to the head

Rosemary Gibson, age 62, was fatally shot by her husband Alan Gibson on 14 April 2016 in their Traralgon home. The death occurred in the context of family violence, with multiple risk factors present: the perpetrator had…

general practicepsychiatry
VIChome2021-02-25

Finding into death of MrP

24y · Male·Gunshot wound to the head

A 24-year-old man with bipolar disorder and ADHD died by gunshot wound to the head approximately 5 months after a serious suicide attempt by overdose. He had been assessed as fit to hold a firearms licence by his treatin…

psychiatrygeneral practicediagnosticsystemmethylphenidate
VIChospital2021-02-25

Finding into death of Laurence Joseph Kermond

65y · Male·Complications of end stage renal failure in a man with multiple co-morbidities

Mr Kermond, a 65-year-old man with intellectual disability, visual and hearing impairment living in a group home, was admitted to Lyndoch Living for respite care on 25 July 2019. He had end-stage renal failure and multip…

general practicenephrology
VIChome2021-02-24

Finding into death of Jordan Malcolm Colin White

1y · Male·Hypoxic ischaemic encephalopathy due to neck compression from faulty portacot

Jordan White, a 14-month-old boy, died from hypoxic ischaemic encephalopathy caused by neck compression when trapped in a faulty portacot. The portable cot had a defective bottom rail that would not lock, leaving it in a…

intensive careneurologysystem
VIChome2021-02-24

Finding into death of AAC

29y · Male·Combined drug toxicity (pregabalin, dihydrocodeine, tramadol, temazepam, lorazep…

A 29-year-old man with class III obesity died from combined drug toxicity involving pregabalin, dihydrocodeine, tramadol, temazepam, and lorazepam. He engaged in prescription medication abuse over 12 months, consulting a…

general practicetoxicologydiagnosticsystempregabalin
VIChospital2021-02-24

Finding into death of Shae Harry Paszkiewicz

40y · Male·Mixed drug toxicity

Shae Paszkiewicz, a 40-year-old man with a long history of drug dependence and incarceration, died from mixed drug toxicity five days after being found unconscious following opioid injection. He had been released from pr…

emergency medicinetoxicologysystemcommunicationheroin
VIC2021-02-24

Finding into death of Mark Capovilla

39y · Male·Choking on a food bolus

Mark Capovilla, a 39-year-old man with severe intellectual disability, epilepsy, and dysphagia, died from choking on food at his day program. He had a documented choking risk but lacked a current mealtime support plan at…

general practiceforensic medicinecommunicationsystem
VIChospital2021-02-23

Finding into death of Christopher Douglas Ritson

22y · Male·Hypoxic ischaemic encephalopathy complicating hanging

Christopher Ritson, a 22-year-old with severe alcohol and polysubstance dependence (ICE, cannabis), depression, anxiety and social phobia, died by suicide via hanging on 17 March 2020, four days after discharge from hosp…

psychiatryemergency medicinecommunicationdelaydiazepam
VICcommunity2021-02-23

Finding into death of Daniel Patrick Frawley

56y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

Daniel Frawley, a 56-year-old former AFL player and coach, died in a single-vehicle collision when his utility struck a tree at high speed (minimum 132 km/h) on a rural road. The coroner found he intentionally took his o…

psychiatryforensic medicinedesvenlafaxine
VIChospital2021-02-10

Finding into death of MRWilson

43y · Male·Liver failure with cirrhosis in the setting of recent paracentesis and Hepatitis…

Mr Wilson was a 43-year-old Aboriginal man with end-stage liver cirrhosis and hepatitis C who died 18 days after emergency umbilical hernia repair and one day after paracentesis drainage of 8 litres of ascites at a rural…

gastroenterologyhepatologycommunicationmorphine
VICaged care2021-02-09

Finding into death of Joyce Drummond

80y · Female·Complications of chronic lymphocytic lymphoma in the setting of multiple medical…

Joyce Drummond, an 80-year-old woman with chronic lymphocytic lymphoma, pancytopenia, and intellectual disability, died from complications of her lymphoma in a palliative care setting. She had lived in disability accommo…

oncologypalliative care
VIChospital2021-02-05

Finding into death of Carl David Waldon

64y · Male·Left-sided intracerebral haemorrhage associated with deep brain stimulator wire …

A 64-year-old man died from intracerebral haemorrhage along a deep brain stimulator wire tract four days after elective neurosurgery for essential tremor. He was readmitted on day 4 with suspected stroke and started on t…

neurosurgeryneurologymedicationsystemenoxaparin

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