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VIC2020-05-05

Finding into death of Richard Neil Gaudion

60y · Male·Injuries sustained in a motor vehicle incident (driver)

Richard Gaudion, a 60-year-old Wild Dog Controller, died when his 4WD vehicle rolled down a steep embankment in remote bushland. WorkSafe identified seven contributing factors: outdated 4WD training (last completed in 20…

occupational and environmental healthforensic medicinesystemdelay
VICaged care2020-05-04

Finding into death of Jane Nola Rolph

90y · Female·Complications of a right fractured neck of femur (operated) sustained in a fall …

A 90-year-old woman with dementia sustained a fractured neck of femur after being nudged by another aggressive dementia-affected resident in an aged care facility, resulting in a fall. Despite appropriate initial managem…

geriatric medicineorthopaedic surgery
VICcommunity2020-05-01

Finding into death of Joelene Therese Dowden

37y · Female·Hypoxic ischaemic brain injury complicating aspiration of gastric contents

Joelene Dowden, 37, died from hypoxic-ischaemic brain injury following aspiration of gastric contents. She presented at Alfred Hospital ED on 9 July 2017 with erratic behaviour, then went to a tram stop where she express…

emergency medicineintensive caredoxylamine
VIC2020-04-28

Finding into death of Justin Dance

47y · Male·Complications of chronic lymphocytic leukaemia in a man with intellectual disabi…

Justin Dance, a 47-year-old man with intellectual disability, epilepsy, and chronic lymphocytic leukaemia, died of complications of his leukaemia while residing in supported disability accommodation. He had a longstandin…

palliative carehaematology
VIChome2020-04-28

Finding into death of Baby M

0y · Male·Unascertained in the setting of detected methylamphetamine

A nearly 4-month-old boy was found unresponsive in his bassinet and could not be revived. Autopsy revealed facial bruising and injuries, and toxicological analysis detected methylamphetamine in his blood and hair. The ca…

forensic medicinetoxicologymethamphetamine
VIChospital2020-04-23

Finding into death of John Alexander King

60y · Male·Mixed drug toxicity

A 60-year-old man with schizophrenia and depression presented to Maroondah Hospital ED with acute psychotic symptoms after stopping his antipsychotic medication (trifluoperazine) due to manufacturer discontinuation. He w…

emergency medicinepsychiatrysystemcommunicationtrifluoperazine
VIChome2020-04-23

Finding into death of Baillee Petra Schneider

25y · Female·Compression of the neck

Baillee Schneider, a 25-year-old woman, died by suicide via neck compression while intoxicated. She had a history of substance misuse (cocaine, alcohol), anxiety treated with Zoloft, and was taking alprazolam. On the mor…

psychiatrytoxicologyalcohol
VICaged care2020-04-22

Finding into death of Dorothy May Nelson

81y · Female·Complications of choking on a food bolus in a woman with dementia

Dorothy May Nelson, an 81-year-old woman with dementia, died from complications of choking on a food bolus at an aged care facility. She was served diced beef in casserole (approximately 4cm bolus found at autopsy, despi…

geriatric medicinepsychiatrydiagnosticproceduralmorphine
VIChospital2020-04-22

Finding into death of Dale Roberts

54y · Male·Aspiration pneumonia

Dale Roberts, a 54-year-old man with cerebral palsy, intellectual disability, epilepsy and severe dysphasia, died from aspiration pneumonia following admission to Box Hill Hospital. He was admitted with aspiration pneumo…

emergency medicinegeneral medicine
VIChome2020-04-17

Finding into death of Karen Frazer

56y · Female·Cardiomegaly

Karen Frazer, a 56-year-old woman with intellectual disability, schizophrenia, anxiety, hypertension, and COPD, died from cardiomegaly (enlarged heart with biventricular hypertrophy). She was found unresponsive on the to…

forensic medicinegeneral practicecarbamazepine
VIChome2020-04-17

Finding into death of Therase Pace

33y · Female·unascertained

Therase Pace, a 33-year-old woman, disappeared on 22 January 1997 from her home in St Albans, Victoria. She was last seen by her husband and children before they left for the beach. The coroner found she is deceased, lik…

VIChospital2020-04-16

Finding into death of Jessica Higgins

33y · Female·Hypoxic ischaemic encephalopathy complicating mixed drug toxicity

Jessica Higgins, a 33-year-old woman with chronic pain on high-dose opioids, underwent ketamine infusion with planned opioid rotation to methadone in May 2017. She was discharged on 23 May on methadone 5mg twice daily pl…

pain medicineemergency medicinecommunicationdiagnosticmethadone
VIC2020-04-08

Finding into death of Kylie Maree Matchett

49y · Female·Complications of Alzheimer's dementia in a woman with Down syndrome

A 49-year-old woman with Down syndrome and Alzheimer's dementia died unexpectedly at her supported accommodation facility. She was found on the floor in the morning, unresponsive. Autopsy confirmed Alzheimer's pathology …

pathologyneurologylamotrigine
VIChome2020-04-07

Finding into death of Jesse Stephen Bird

32y · Male·neck compression in the circumstances of hanging

Jesse Bird, a 32-year-old Torres Strait Islander veteran, died by suicide in June 2017 after struggling to navigate the Department of Veterans' Affairs (DVA) compensation system. He served in Afghanistan in 2009, develop…

psychiatryparamedicinesystemcommunicationduloxetine
VIC2020-04-06

Finding into death of Robert James Lawerence

29y · Male·Shotgun wound to the head

Robert James Lawrence, a 29-year-old man with complex mental health needs including ADHD, depression, anxiety, Tourette's syndrome, and borderline personality traits, died from a self-inflicted shotgun wound. He held a C…

psychiatrypsychologycommunicationsystem
VIC2020-04-06

Finding into death of Darren Brandon

51y · Male·hypoxic-ischemic encephalopathy due to hanging

Darren Brandon died by hanging in prison on 10 June 2018, two days after arriving at Melbourne Assessment Prison. He was a 51-year-old man with acquired brain injury from a 2003 motorcycle accident, depression, and histo…

psychiatryforensic medicinecommunicationsystemoxycodone
VIChospital2020-03-30

Finding into death of Timothy Leighton Richardson

82y · Male·Ischaemic heart disease

Timothy Leighton Richardson, 82, died of ischaemic heart disease while in custody at Port Phillip Prison. He had extensive cardiac history including prior coronary artery grafts and a recent myocardial infarction in Janu…

cardiologyforensic medicine
VICcommunity2020-03-27

Finding into death of Richard Armstrong Lyon

19y · Male·Drowning

A 19-year-old man drowned in Baxter Park Dam after entering water despite being described as not a strong swimmer. He had been joking about drowning earlier during the swimming session and when he genuinely became distre…

cannabis
VIChospital2020-03-26

Finding into death of Matthew John George

45y · Male·Global cerebral hypoxia following cardio-respiratory collapse due to anaphylaxis…

A 45-year-old man with poorly controlled diabetes, ischaemic heart disease, and recurrent lower limb infections died from anaphylaxis to intravenously administered flucloxacillin. He presented with sepsis secondary to a …

general medicineinfectious diseasescommunicationdiagnosticflucloxacillin
VIC2020-03-23

Finding into death of Scott Andrew Fewson

46y · Male·Multiple injuries sustained in a motorcycle incident (driver)

Scott Fewson, a 46-year-old motorcycle rider, died from multiple injuries sustained in a single-vehicle motorcycle collision after spending the afternoon consuming alcohol and taking oxycodone and citalopram. His blood a…

alcohol

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