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NSWhome2025-12-17

Inquest into the death of MQ

55y · Female·acute necrotising bronchopneumonia

MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…

general practiceemergency medicinediagnosticdelay
VICmental health2025-12-11

Finding into death of Tania Louise De Jong

48y · Female·Mixed drug toxicity (morphine, codeine, venlafaxine, amitriptyline and zopiclone…

A 48-year-old woman with depression, anxiety, and bipolar disorder died from mixed drug toxicity while on voluntary inpatient psychiatric admission. She had undisclosed significant illicit drug use, which was not identif…

psychiatrygeneral practicesystemcommunicationmorphine
TAShome2025-12-11

Coroner's Finding: de-identified SH

57y · Female·aspiration of gastric contents caused by combined drug and alcohol toxicity resu…

A 57-year-old woman with complex medical and mental health conditions died from aspiration of gastric contents caused by combined drug and alcohol toxicity. She had severe chronic pain following abdominal surgeries, opio…

general practicepharmacologymedicationmethadone
NSWcommunity2025-12-09

Inquest into the deaths of Lynette Thompson and Alan Fletcher

58y · Female; male·Lynette: Thermal injuries (extensive burns) and complications thereof; Alan: Nec…

Two related deaths from domestic violence murder-suicide. Lynette Thompson (58, Aboriginal woman) died from severe burns inflicted by her partner Alan Fletcher (59) on 8 November 2020; Alan subsequently died by hanging. …

communicationsystempetrol
TAShospital2025-12-09

Coroner's Finding: de-identified EM

76y · Female·sepsis as a result of myocarditis and tricuspid valve endocarditis (infective en…

A 76-year-old woman with vascular dementia and emphysema was admitted with sepsis of unknown origin, treated with antibiotics, and discharged after 12 days with improving symptoms. She re-presented 14 days later with rec…

emergency medicinecardiologydiagnosticcommunicationantibiotics
WA2025-12-08

Inquest into the Death of Ashley James BROPHO

Male·Neck injury in a man with atherosclerotic heart disease

Ashley James Bropho, a vulnerable remand prisoner with intellectual impairment, schizophrenia, diabetes, previous myocardial infarction with stent, and atherosclerotic heart disease, was killed on 9 March 2023 at Hakea P…

correctional healthsystem
NSWhospital2025-12-08

Inquest into the death of Katrina McGrady

43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm

Trina McGrady, a 43-year-old Goomeroi woman, died from subarachnoid haemorrhage due to a ruptured berry aneurysm on 15 September 2020. She had been admitted to John Hunter Hospital following incidental discovery of two l…

neurosurgeryradiologycommunicationdiagnosticaspirin
VIChospital2025-12-08

Finding into death of Graeme William Kenny

61y · Male·Right lower lobe pneumonia

Graeme William Kenny, a 61-year-old man with trisomy 21 and dementia, died from right lower lobe pneumonia on 25 December 2024 at Monash Medical Centre following palliative care. He developed upper respiratory symptoms o…

emergency medicinegeneral practicediagnosticdelayibuprofen
NSW2025-12-08

Inquest into the death of Benjamin Cullen

41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…

Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from P…

neurologyemergency medicinemedicationsystemlevetiracetam
NThome2025-12-05

Inquest into the death of Kumanjayi Fly

2y · Male·Hypoxic-ischaemic encephalopathy due to out of hospital cardiac arrest following…

A 2-year-old toddler died after falling into a septic tank in his family's public housing home in a remote Northern Territory community. The septic tank access cover was corroded and insecure due to systemic failures in …

systemdelay
VICcommunity2025-12-04

Finding into death of Mr PNF

60y · Male·Neck compression secondary to hanging

A 60-year-old man with Type 2 diabetes and low mood died by hanging within 24 hours of being interviewed by police regarding child sexual abuse allegations. While police identified that suspects are at heightened suicide…

general practicepsychiatrycommunicationsystemfluoxetine
VIChome2025-12-04

Finding into death of Raymond John Flaherty

57y · Male·Mixed drug toxicity (heroin, methadone, benzodiazepines including novel benzodia…

Raymond John Flaherty, a 57-year-old Wurundjeri man with longstanding opioid and benzodiazepine dependence, died from mixed drug toxicity involving heroin, methadone, prescribed diazepam, unprescribed benzodiazepines inc…

addiction medicinegeneral practicesystemcommunicationheroin
QLDhospital2025-12-04

Inquest into the death of Dylan James Bell

28y · Male·Hanging

Dylan Bell, 28, died by hanging following discharge from Redland Hospital ED where he presented with acute psychosis, suicidal and homicidal ideation, and made three self-harm attempts by strangulation. Despite a concern…

psychiatryemergency medicinediagnosticcommunicationLSD
TAScommunity2025-12-03

Coroner's Finding: de-identified JI

54y · Male·Global hypoxic brain injury, cardiac arrest and blunt trauma to cervical spine

JI, a 54-year-old man with chronic schizophrenia, died from global hypoxic brain injury, cardiac arrest and cervical spine trauma following a fall onto a metal grate during an altercation with another resident at support…

psychiatrygeneral practicesystemdiazepam
TAShome2025-12-02

Coroner's Finding: de-identified DQ

54y · Female·mixed drug toxicity (methadone and diazepam)

A 54-year-old woman with long-standing opioid use disorder died from mixed methadone and diazepam toxicity. She had tripled her methadone dose by injecting additional takeaway doses alongside her prescribed pharmacy dose…

general practicepharmacologydiagnosticmedicationmethadone
ACThospital2025-12-02

Inquest Into The Death Of Bk

52y · Male·Multiple injuries sustained in a motor vehicle accident

A 52-year-old man died from multiple injuries sustained in a motorcycle accident after losing control on a residential street. Critical contributing factors included: riding while significantly intoxicated (blood alcohol…

alcohol
QLD2025-12-01

Non-Inquest findings into the deaths of Ashley Pangana Morris and Humbereto Ferreira Leite

Male·Multiple injuries due to or as a consequence of concrete wall collapse

Two workers, Ashley Morris (34) and Humberto Leite (55), were fatally crushed by collapsing concrete wall panels on 6 October 2016 while installing foul water settling tanks at Eagle Farm Racecourse. The work system desi…

occupational and environmental healthproceduralsystem
WA2025-11-28

Inquest into the Death of Cleveland Keith DODD

16y · Male·complications of ligature compression of the neck (hanging)

A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…

psychiatrypsychologyproceduralcommunication
TAShospital2025-11-28

Coroner's Finding: Clark, Dennis

83y · Male·Sepsis due to staphylococcus aureus bacteraemia following infection of a left an…

An 83-year-old man with heart and kidney failure died from sepsis caused by MSSA bacteraemia following infection at a peripheral intravenous catheter (PIVC) insertion site. Ambulance paramedics inserted the PIVC 56 hours…

emergency medicinesurgeryproceduralsystem
NSW2025-11-27

Inquest into the deaths of Lilie James and Paul Thijssen

21; 23y · Female; male·Lilie: multiple blunt force injuries to the head and neck. Paul: multiple blunt …

Lilie James, aged 21, was killed by Paul Thijssen, aged 23, a colleague at St Andrew's Cathedral School, using a hammer in a bathroom on 25 October 2023. Paul killed himself by jumping from a cliff at Diamond Bay Reserve…

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