Coronial
TAShospital2026-01-21

Coroner's Finding: de-identified KW

87y · Female·right thigh haematoma as a consequence of a periprosthetic fracture of the right…

An 87-year-old woman with multiple comorbidities (diabetes, atrial fibrillation, peripheral vascular disease) sustained a periprosthetic fracture requiring distal femur replacement. She deteriorated significantly during …

orthopaedic surgerygeriatric medicinediagnosticsystem
NSW2025-09-15

Inquest into the death of Robert Sievers

81y · Male·COVID-19 infection on a background of Type 2 Diabetes and end stage chronic kidn…

Robert Sievers, an 81-year-old man incarcerated since 2001, died from COVID-19 infection on a background of type 2 diabetes and end-stage chronic kidney disease. Despite multiple warnings about vaccination, Sievers refus…

geriatric medicinepalliative careantiviral medication
NThospital2008-12-23

Inquest into the death of Jenissa Ryan

14y · Female·blunt force head injury

A 14-year-old Aboriginal girl with newly diagnosed idiopathic thrombocytopenic purpura (ITP) and critically low platelet count (5,000/mm³) absconded from Alice Springs Hospital on 27 January 2006. Hospital staff failed t…

infectious diseaseshaematologycommunicationsystemintragam
VICaged care2024-03-28

Finding into death of Shirley Hill Jones

85y · Female·Complications of a left ankle fracture (operated)

An 85-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, hypertension, prior stroke) sustained a left ankle fracture requiring surgical repair. A significant delay occurred in removing her pla…

geriatric medicineorthopaedic surgerycommunicationdelayoxycodone
VIChospital2024-10-10

Finding into death of Makayla Lee Wadeson

9y · Female·Streptococcus pneumoniae and Candida albicans pneumonia and empyema in a girl wi…

Makayla Lee Wadeson, a 9-year-old autistic girl with ulcerative colitis on immunosuppressive therapy, presented to the emergency department with ear infection symptoms on 29 July 2022. She was triaged Category 4 and disc…

emergency medicinepaediatricsdiagnosticsystemcefalexin
WAhospital2022-01-05

Inquest into the Death of Terrence Alexander Penman WELLS

61y · Male·metastatic oesophageal neuroendocrine carcinoma

Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attribut…

oncologypalliative caremedicationsystempantoprazole
WAhospital- 8 July 2014

Inquest into the Death of Delray BEASLEY

56y · Male·unascertainable; complications of liver cirrhosis and/or exposure most likely

Delray Beasley, a 56-year-old Aboriginal man with chronic liver cirrhosis from longstanding alcohol abuse, was admitted to Kalgoorlie Hospital in May 2010 following an alleged assault. He was initially evaluated for poss…

emergency medicineneurosurgerysystemdiazepam
VICaged care2020-07-06

Finding into death of Irene Florence Curran

79y · Female·Ischaemic bowel in the setting of cardiomegaly, pneumonia and chronic renal fail…

A 79-year-old woman died from ischaemic bowel in the setting of cardiomegaly, pneumonia and chronic renal failure, four days after discharge from hospital following a hysterectomy for endometrial cancer. Key clinical les…

gynaecologygeneral practicecommunicationsystemoxycodone
VIChospital2012-01-31

Finding into death of Judith Elizabeth Heath

68y · Female·Massive blood loss due to disconnection of haemodialysis machine

Judith Heath, age 68, died from acute blood loss on 7 September 2006 at The Alfred Hospital during routine haemodialysis for end-stage renal failure. The Luer-Lok connection between her arteriovenous catheter and the hae…

nephrologyproceduralsystemheparin
QLDcommunity2016-12-21

Capps, Ruth

75y · Female·multiple injuries due to or as a consequence of motor vehicle collision

Ruth Capps, 75, died in a motor vehicle collision after drifting into oncoming traffic. She had multiple medical conditions including diabetes, sleep apnoea, chronic back pain, osteoarthritis, and recurrent falls. Despit…

general practiceoccupational therapydiagnosticcommunicationnitrazepam
QLDhome2015-01-29

Daw, Lilly Ella - Non-inquest findings

1y · Female·cystic encephalomalacia

Lilly Ella Daw, born at 27 weeks gestation as a monochorionic diamniotic twin following intrauterine death of her co-twin, died at one month of age from cystic encephalomalacia. The surviving twin had a documented 20% ri…

obstetricspaediatricscommunicationdelay
WAhome2020-01-16

Inquest into the Deaths of Zaraiyah-Lily HEADLAND and Andreas Hohaia HEADLAND

Unknown·asphyxiation in a child with drug effect

Two young children, aged 5 and 3, died following filicide by their father during a parental separation. The father purchased sedative medication (Restavit) on the afternoon of the deaths and administered it to the childr…

emergency medicinepaediatricssystemdelaydoxylamine
VICaged care2025-05-22

Finding into death of Veronica Lesley Roberts

75y · Female·Ischaemic heart disease in the setting of unstable type 2 diabetes mellitus and …

Veronica Roberts, 75, died from ischaemic heart disease complicated by unstable diabetes and a medication error. On 4 October 2020, her insulin dose was increased to 20 units daily, but due to Electronic Medical Record (…

geriatric medicinegeneral medicinemedicationsystemglargine insulin
WAhome2025-02-12

Inquest into the Death of Kimberley Michael VULICH

64y · Male·complications in association with thermal injuries in a man with underlying chro…

Kim Vulich, a 64-year-old man with decompensated liver cirrhosis from chronic alcohol use, developed hepatic encephalopathy and cognitive impairment including possible Korsakoff syndrome. Despite SAT guardianship orders …

general medicinegeriatric medicinecommunicationdelay
TAShome2018-11-05

Coroner's Finding: Unwin, David Paul

55y · Male·probable sepsis in the setting of immunosuppression, a skin wound and chronic di…

David Paul Unwin, a 55-year-old kidney transplant recipient with polycystic kidney disease, died of sepsis in January 2017. He presented with progressive symptoms including chronic diarrhoea, weight loss (16kg in 8 weeks…

nephrologygeneral practicediagnosticdelay
NThospital2018-01-11

Inquest into the death of Addison Anthony

35y · Male·Active rheumatic pancarditis complicated by pulmonary arterial hypertension, pne…

A 35-year-old Aboriginal man died from rheumatic pancarditis complicated by pulmonary hypertension, pneumonia and unspecified connective tissue disease. He had presented repeatedly to Katherine Hospital with symptoms sug…

emergency medicineintensive carecommunicationdiagnosticdicloxacillin
VIChospital2019-08-01

Finding into death of Tyla Jade Hovenbitzer

18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…

An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…

paediatricsgeneral practicesystemdelaytemazepam
NTcommunity2011-07-27

Inquest into the death of Marilyn Lalara

48y · Female·acute myocarditis resulting from systemic viral infection

A 48-year-old Aboriginal woman with chronic diseases (diabetes, COPD, ischaemic heart disease) presented with ongoing chest infection symptoms across multiple clinic visits between 30 March and 4 April 2010. Despite five…

emergency medicinecardiologydiagnosticdelayantibiotics
NSWhospital2015-08-17

Inquest into the death of Manjit SINGH

33y · Male·hypoxic respiratory failure following right pneumonectomy for treatment of sever…

Manjit Singh, a 33-year-old Indian 457 visa worker, died from hypoxic respiratory failure following a pneumonectomy for treatment of severe pulmonary tuberculosis. He had latent TB identified pre-arrival in India. Critic…

respiratory medicinecardiothoracic surgerydiagnosticcommunicationtuberculosis medications
VIChospital2012-06-22

Finding into death of Sebastian Hewitt

2y · Male·Perinatal asphyxia leading to cerebral anoxia and subsequent multi-organ failure

… assessment: persistently pale newborns with cord blood pH 7.02 and hypothermia require investigation for anaemia and foetal-maternal haemorrhage, and repeat blood gas analysis within 30-60 minutes of delivery. Signific…

obstetricspaediatricsdiagnosticdelay

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