Coronial
NSWhospital2020-03-04

Inquest into the death of Paul MORTIMER

65y · Male·ischaemic heart disease following complications of colorectal surgery

A 65-year-old man with significant comorbidities (cardiomyopathy, diabetes, obesity) underwent colorectal surgery for adenocarcinoma. Post-operative course was complicated by anastomotic breakdown causing sepsis on day 1…

colorectal surgeryintensive careproceduralsystemenoxaparin
VICcommunityPodcast2024-03-15

Finding into death of Colleen Mary South

58y · Female·Unascertained

Colleen Mary South, aged 58, was found deceased on 8 August 2022 under a tree in a remote rural paddock in Bunguluke, Victoria, approximately 1.5 kilometres from her abandoned vehicle. She had a significant psychiatric h…

psychiatryemergency medicinesystemdelayaripiprazole
VIChospital2021-10-25

Finding into death of MR XH

46y · Male·Hypoxic ischaemic brain injury complicating a cardiac arrest during anaesthetic …

A 46-year-old male underwent elective inguinal hernia repair at a private hospital. During anaesthetic induction, he experienced cardiac arrest. The endotracheal tube (ETT) was visualized passing through the vocal cords,…

anaesthesiaintensive carediagnosticproceduralfentanyl
VIChome2016-06-23

Finding into death of John Charles Prohasky

66y · Male·unascertained

A 66-year-old man with insulin-dependent diabetes mellitus and severe hypoglycaemia unawareness died on 20 June 2013, the day after commencing a Medtronic Paradigm insulin pump. He was found collapsed at home after plann…

endocrinologysystemcommunicationinsulin - rapid-acting
SA2012-11-14

Coroner's Finding: Heyward Neil Wills

53y · Male·neck compression due to hanging

Neil Heyward, aged 53, died by hanging in Port Augusta Prison on 6 June 2009 while on remand for murder. He had been in custody since December 2007 and was managed by prison social workers and medical staff. Although he …

psychiatrycorrectional healthsystemcommunication
WAhospital2016-02-05

Inquest into the Death of Pauline Margaret DODD

51y · Female·Ischaemic heart disease

Pauline Margaret Dodd, 51, died of ischaemic heart disease at Sir Charles Gairdner Hospital on 4 March 2014. She was an involuntary psychiatric patient with long-standing bipolar affective disorder, complicated by childh…

psychiatrycardiologydiagnosticolanzapine
VIChome2026-03-19

Finding into death of Aisha Natasha Khan

44y · Female·Mixed alcohol and drug toxicity (tapentadol, diazepam, mirtazapine, amitriptylin…

Aisha Natasha Khan, 44, died from mixed alcohol and drug toxicity following an intentional polypharmacy overdose with alcohol consumption. She had a history of depression, alcohol use disorder, chronic pain, and two prio…

psychiatryemergency medicinesystemdelaytapentadol
VIChospital2020-05-05

Finding into death of John Hayle

76y · Male·Bronchopneumonia in a man with ischaemic heart disease and treated spinal crush …

John Hayle, a 76-year-old with Alzheimer's dementia, ischaemic heart disease, and spinal fractures sustained a T11/12 flexion-distraction fracture on 9 June 2017. Over three weeks, he developed progressive bilateral lowe…

neurosurgerygeriatric medicinediagnosticcommunicationmk8931
VIChospital2017-02-17

Finding into death of Christopher Albert Nance

67y · Male·ischaemic heart disease

A 67-year-old man with ischaemic heart disease and paroxysmal atrial fibrillation underwent arthrotomy for septic arthritis of the knee. He developed post-operative delirium attributed to anaesthesia, analgesics (tramado…

cardiologyorthopaedic surgerycommunicationproceduraltramadol
WAmental health2024-08-28

Inquest into the Death of Peter Jonathon Rex BOLTON

36y · Male·ligature compression of the neck (hanging)

A 36-year-old man with schizoaffective disorder, traumatic brain injury, and substance use disorder died by ligature while an involuntary inpatient in a locked mental health ward. He was on hourly observations and had re…

psychiatryemergency medicinehaloperidol
VIChome2019-12-11

Finding into death of Maddox Garry Wheeler

0y · Male·Unascertained

A 10-week-old boy born at 35 weeks gestation was found asleep on his mother's chest while she was asleep on a couch and died from an unascertained cause. Post-mortem toxicology detected methamphetamine and cannabis; the …

neonatologyobstetricscommunicationdelaymethamphetamine
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
VIChomePodcast2018-11-09

Finding into death of Clarence Tuivaiese Nicholas Leo

37y · Male·Acute asthma (thunderstorm asthma event)

37-year-old male died from acute asthma during the unprecedented Melbourne thunderstorm asthma event (21-22 November 2016). He had moderate to severe asthma with suboptimal preventer medication use and recently diagnosed…

emergency medicineparamedicinedelaysalbutamol
VICcommunity2018-12-18

Finding into death of LF M

52y · Male·Multiple injuries sustained in a motor vehicle incident (driver) in a man with a…

A 52-year-old man with epilepsy died in a motor vehicle collision when his car struck a parked truck at high speed with no evidence of braking. Witness accounts and collision reconstruction suggested he experienced a sei…

neurologycardiologycommunicationsystemtopiramate
WAhome2023-06-28

Inquest into the Death of Nicholas Arthur CRIPPS

47y · Male·combined acute effects of multiple drugs in obese man with enlarged heart and ar…

Nicholas Cripps, a 47-year-old man with treatment-resistant schizophrenia, substance use disorder, and antisocial personality disorder, died from combined acute effects of multiple drugs (methylamphetamine, quetiapine, p…

psychiatrygeneral practicesystemmethamphetamine
VIChospital2018-04-26

Finding into death of James Pickup

59y · Male·Pulmonary embolus

A 59-year-old man with obesity, smoking history, hypertension, and hypercholesterolaemia presented to the ED with two days of acute onset shortness of breath. The registrar diagnosed COPD based on normal vitals, clinical…

emergency medicinerespiratory medicinediagnosticcommunication
VIChome2014-05-15

Finding into death of Georgia Susan Cheal

31y · Female·Pneumonia; combined drug toxicity (including marijuana), smoking, pathological o…

Georgia Cheal, a 31-year-old with complex medical history including chronic pain, major depression, and obesity, died from pneumonia exacerbated by combined drug toxicity from multiple prescription medications, cannabis,…

general practicepsychiatrycommunicationsystemoxycodone
VIChome2016-02-29

Finding into death of Yamini Bhadrayu Patel

48y · Female·Ischaemic brain injury secondary to toxicity to tramadol and temazepam

A 48-year-old woman died from ischaemic brain injury caused by overdose of tramadol and temazepam. She was found unresponsive at home on 10 October 2009 after consuming these medications. Her family and GP Dr D. failed t…

general practiceintensive carediagnosticdelaytramadol
QLDhospital2010-05-07

Cramb, Fay - aka Valmae Beck

64y · Female·Haemorrhage into atheromatous plaque, due to coronary atherosclerosis

Fay Cramb, a 64-year-old woman imprisoned for 20+ years, died on 27 May 2008 from coronary atherosclerosis with haemorrhage into atheromatous plaque. She suffered an acute cardiac event on 5 May 2008 requiring emergency …

cardiologyintensive caresystem
WA2025-12-17

Inquest into the Death of Jamie Frederick GINN

50y · Male·cocaine toxicity

Jamie Frederick Ginn, 50, died from cocaine toxicity on 10 October 2023 while in custody at Perth Watch House (PWH). He had ingested approximately one teaspoon of cocaine hydrochloride; the coroner could not determine wh…

systemcocaine

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