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WAhospital2025-02-21

Inquest into the Death of Fabian Alec COFFIN

51y · Male·complications of myocardial infarction in association with ischaemic heart disea…

A 51-year-old Aboriginal male prisoner with multiple cardiovascular risk factors (diabetes, hypertension, high cholesterol, chronic kidney disease, obesity, smoking) died on 5 February 2024 from myocardial infarction. He…

cardiologycorrectional health
NSWprison2025-02-19

Inquest into the death of Daniel Munro Lewis Turnbull

35y · Male·Hyponatraemia, with psychogenic polydipsia and schizophrenia/schizoaffective dis…

Daniel Turnbull, aged 35, died in custody from hyponatraemia secondary to psychogenic polydipsia whilst in a 24-hour surveillance cell at Bathurst Correctional Centre. He had a long history of schizophrenia managed with …

psychiatryintensive carecommunicationsystemolanzapine
NTmental health2025-02-14

Inquest into the death of Pukumani

47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…

Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…

psychiatryemergency medicinediagnosticcommunicationketamine
VIChospital2025-02-13

Finding into death of Jack Brownlee

21y · Male·Complications of injuries sustained when a trench wall collapsed

Jack Brownlee, 21, died from crush injuries sustained in a workplace trench collapse at a construction site. Despite family concerns that excavator use during rescue exacerbated his injuries, expert geotechnical and resc…

emergency medicinetrauma surgerysystemmidazolam
VIChospital2025-02-12

Finding into death of Alexander Cameron

40y · Male·Aspiration pneumonia

Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia f…

intensive caregeneral surgeryclozapine
VIChospitalPodcast2025-02-05

Finding into death of Daniel Francis McNeill

39y · Male·Complications following extradural haemorrhage (operated) sustained in an electr…

A 39-year-old man died from complications of extradural haemorrhage sustained in an e-scooter fall. He was riding a high-powered e-scooter (capable of 84 km/h, exceeding legal limits) while under the influence of methyla…

emergency medicineneurosurgerymethamphetamine
VIChospital2025-02-04

Finding into death of Tan Van Tran

53y · Male·Gastrointestinal haemorrhage complicating recent PEG insertion with stroke as a …

Tan Van Tran, a 53-year-old man with prior stroke causing severe dysphagia, died from gastrointestinal haemorrhage complicating recent PEG insertion. He was admitted with aspiration pneumonia and underwent PEG placement …

gastroenterologyemergency medicinepiperacillin-tazobactam
VIChospital2025-01-30

Finding into death of Janelle Maree Lavery

56y · Female·Complications of Angelman's syndrome - aspiration pneumonia

Janelle Maree Lavery, a 56-year-old woman with Angelman's syndrome, cerebral palsy, epilepsy, intellectual disability, dysphagia, and severe kyphoscoliosis, died of aspiration pneumonia following a one-month hospital adm…

emergency medicinepalliative care
TAShospital2025-01-29

Coroner's Finding: de-identified IM

37y · Female·sepsis due to necrotising fasciitis following abdominoplasty with liposuction

A 37-year-old woman died from sepsis due to necrotising fasciitis following abdominoplasty and liposuction. She was discharged on post-operative day 4 with severe pain, nausea, and vomiting, which were attributed to norm…

plastic and reconstructive surgerygeneral practiceoxycodone
VIChospital2025-01-29

Finding into death of Amir Mohammad Iran

2y · Male·Hyaline membrane disease and pneumonia in the setting of pneumothorax

A 2-day-old term infant (2670g, small-for-gestational-age) presented with respiratory distress at 11 hours of life. A capillary blood gas at 1:14pm showed mixed respiratory and metabolic acidosis indicating decompensatio…

neonatologyobstetricsdiagnosticdelaysurfactant
VIChospital2025-01-28

Finding into death of Dustin Buckley

17y · Male·Gunshot wound to the head

Dustin Buckley, 17, died from a gunshot wound to the head at Royal Melbourne Hospital on 27 August 2017. The incident occurred during target shooting at Cat Track when KD fired a .22 rifle that discharged, striking Dusti…

trauma surgeryemergency medicinesystemproceduralmidazolam
VIChospital2025-01-22

Finding into death of Milan Rajic

40y · Male·Traumatic head injury sustained in an e-bike incident

A 40-year-old man died from traumatic brain injury sustained in an unwitnessed fall from an electric bicycle. He was riding without a helmet after consuming approximately three beers over several hours. He returned home …

neurosurgerytrauma surgery
TAShospital2025-01-21

Coroner's Finding: Connlley, Maurice Gordon

76y · Male·Extensive small bowel infarction caused by superior mesenteric artery thrombus

A 76-year-old man presented to ED with sudden onset left-sided abdominal pain, vomiting and bowel incontinence. Initial CT imaging was reassuring. However, mesenteric ischaemia—characterised by severe pain without signif…

emergency medicinesurgerydiagnosticdelayanticoagulant
TAShospital2025-01-20

Coroner's Finding: Lowe, Wayne Anthony

58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humeru…

Wayne Anthony Lowe, aged 58, died of multiorgan failure due to sepsis following repeated humeral fractures sustained in falls. He was admitted with a right proximal humeral fracture from an intoxicated fall, discharged a…

orthopaedic surgerygeneral medicinesystemdelay
VIChospital2025-01-20

Finding into death of Sheldon Jay Broderick

48y · Male·Head injury

A 48-year-old man died from a head injury sustained during a confrontation at a burgled fish and chip shop. He had broken into the shop early on 20 June 2022. A neighbour, hearing the break-in, confronted him with a cric…

trauma surgeryneurosurgerymethamphetamine
TASaged care2025-01-14

Coroner's Finding: Rickard-Simms, Adrienne Rosemary

75y · Female·postoperative delirium/exacerbation of community acquired pneumonia following le…

A 75-year-old woman with chronic kidney disease, anemia, and significant mobility impairment fell in her aged care facility despite documented high falls risk and appropriate preventive measures. She sustained a neck of …

geriatric medicineorthopaedic surgery
NThospital2025-01-10

Inquest into the death of Mati Tamwoy

66y · Male·infectious complications of plasmablastic myeloma

Mati Tamwoy, a 66-year-old Aboriginal man, died in ICU from infectious complications of plasmablastic myeloma after 661 days on remand. He received excellent oncological care including chemotherapy and radiotherapy. Howe…

haematologyoncologysystemcommunicationchemotherapy agents
VIChospital2025

Finding into death of TBL

81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…

An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…

psychiatrygeneral practicesystemdelayrisperidone
TAShospital2024-12-17

Coroner's Finding: Brown, Paul Louis

64y · Male·Subdural haematoma with mass effect following thrombolysis for acute myocardial …

A 64-year-old man with complex medical history including diabetes, mental illness, chronic alcohol misuse, and previous traumatic brain injury was admitted with diabetic ketoacidosis and acute kidney injury. He developed…

intensive carecardiologytenecteplase
VIC2024-12-16

Finding into death of Caroline Monique Hall

52y · Female·Spinal injuries sustained in falls in a woman with multiple medical comorbiditie…

Caroline Monique Hall, a 52-year-old woman with intellectual disability, epilepsy, schizophrenia, and multiple comorbidities living in supported disability accommodation, died from spinal injuries sustained in falls. She…

general practiceemergency medicinediagnosticdelaymorphine
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