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VIC2025-11-12

Finding into death of Wendy Ann McCabe

40y · Female·hypoxic ischaemic encephalopathy due to ligature compression of the neck

Wendy McCabe, a 40-year-old woman with a history of depression, anxiety, substance use and previous self-harm, died of asphyxiation from ligature compression after fashioning a noose from a standard blanket in her police…

correctional healthemergency medicineproceduralcommunicationmethadone
VIC2025-11-10

Finding into death of Andrew Phillip John Kursinskis

57y · Male·Complications following food aspiration in a man with multiple co-morbidities

Andrew Kursinskis, a 57-year-old man with intellectual disability, dysphagia, autism, epilepsy and pica, died from complications following aspiration of chicken schnitzel while living in supported disability accommodatio…

speech pathologyemergency medicinesystemcommunicationlevetiracetam
VIChospital2025-11-10

Finding into death of Panayotis (Peter) Pavlis

83y · Male·Pneumonia

An 83-year-old man remanded in custody at Ravenhall Correctional Centre died of pneumonia in St Vincent's Hospital. He had rapidly progressive dementia since 2021, was immobile and bedbound in his final six months, and h…

emergency medicinepalliative care
VIChospital2025-11-10

Finding into death of Jason Hosier

39y · Male·mixed drug toxicity (methadone, benzodiazepines, olanzapine, zopiclone)

Jason Hosier, a 39-year-old man with complex mental health and substance use history, died from mixed drug toxicity following discharge from Sunshine Hospital. He was subject to an inpatient temporary treatment order and…

emergency medicinepsychiatrycommunicationsystemmethadone
ACThospital2025-11-05

Inquest Into The Death Of Ms Tl A Pseudonym

19y · Female·multiple injuries sustained in a motor vehicle collision

A 19-year-old woman died from multiple injuries sustained in a motor vehicle collision on Black Mountain Drive, Canberra on 4 June 2022. She was driving a 1986 Toyota sedan at approximately 80 km/h when she lost control …

emergency medicinetrauma surgery
WAcommunity2025-11-05

Inquest into the Death of Child WK (Name Subject to Suppression Order)

8y · Male·Streptococcus pyogenes and parechovirus infection

An eight-month-old boy in state child protection care died from Streptococcus pyogenes and parechovirus coinfection. He presented to regional ED on 2 September with fever and ear infection signs, then 4 September with mi…

general practiceemergency medicineamoxicillin
NSWcommunity2025-11-03

Inquest into the death of JF

60y · Female·multiple injuries

JF, a 60-year-old woman with recurrent major depressive disorder and a history of suicide attempts, died by suicide at Redhead Headland on 12 February 2024. Despite three prior psychiatric hospitalizations and documented…

psychiatrygeneral practicesystemmirtazapine
QLD2025-10-29

Inquest into the death of Selesa Tafaifa

44y · Female·Cardiac arrest in the context of several contributory factors (physical exertion…

Selesa Tafaifa, a 44-year-old woman with Samoan heritage, died in custody at Townsville Women's Correctional Centre on 30 November 2021 during physical restraint by correctional officers, including application of a safet…

forensic medicineemergency medicineproceduralsystemmixtard 30/70 insulin
VIC2025-10-29

Finding into death of David James Klingberg

55y · Male·Complications of traumatic head injury sustained in a workplace incident (pallia…

David Klingberg, a 55-year-old experienced pile testing engineer, died from traumatic head injury sustained when an auxiliary line hook on a piling rig struck him in the face at a construction site. The hook became jamme…

emergency medicineintensive caresystemmorphine
VIChospital2025-10-28

Finding into death of Jean Elizabeth Crocker

90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …

A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …

emergency medicinegeneral medicinemedicationdiagnosticwarfarin
VIChospital2025-10-28

Finding into death of Kenneth James Anderson

85y · Male·Liver ischaemia and portal vein thrombosis complicating emergency cholecystectom…

Kenneth James Anderson, an 85-year-old man with intellectual disability and multiple comorbidities including diabetes, pancreatitis, and gallstones, died following emergency cholecystectomy for acute cholecystitis with M…

general surgeryintensive careantibiotics
NTPodcast2025-10-24

Inquest into the death of Ebony Thompson

1y · Female·hypoxic brain injury caused by pressure to the neck from entrapment on a loop-to…

Ebony Thompson, aged 22 months, died from hypoxic brain injury caused by neck entrapment in a loop-topped chickencoop gate at a childcare centre. She became trapped while standing on a tricycle attempting to view chicken…

paediatricsemergency medicinesystemcommunication
QLDhospital2025-10-24

Non-Inquest findings into the death of Ms G

76y · Female·Head injury comprised of subdural haematoma, subarachnoid haemorrhage with brain…

A 76-year-old woman died from complications of a severe head injury sustained in a motor vehicle collision. She was initially managed conservatively at a regional hospital, but her condition deteriorated markedly at 9pm …

neurosurgeryemergency medicinecommunicationdelay
QLDhospital2025-10-23

Inquest into the death of Shirley Elizabeth Haggett

78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…

78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…

anaesthesiaplastic and reconstructive surgerysystemdiagnosticmidazolam
QLDhospital2025-10-23

Inquest into the death of Kamalavati Sundar

86y · Female·Metastatic ovarian cancer (high-grade serous carcinoma)

An 86-year-old woman serving a life sentence died of metastatic ovarian cancer in palliative care. After diagnosis in April 2023, treatment was appropriately limited to symptom management given her advanced dementia, mak…

gynaecologypalliative careoxycodone
SAcommunity2025-10-20

Coroner's Finding: Kennedy, John Douglas

65y · Male·Ischaemic heart disease on a background of hypertension

John Kennedy, 65, died from ischaemic heart disease with hypertension on 16 April 2020 after a 24-minute delay in ambulance dispatch. He called triple zero at 00:19 with severe chest pain and difficulty breathing (Priori…

emergency medicinecardiologycommunicationsystematenolol
NSWhospital2025-10-20

Inquest into the death of BR

1y · Unknown·unascertained

A 12-month-old infant suffered unexpected cardiac arrest at home nine days after receiving routine MMR, meningococcal, and pneumococcal vaccinations. He presented to Manning Base Hospital on 27 July 2020 with fever (38.5…

emergency medicineintensive carecommunicationsysteminfanrix hexa
QLDhome2025-10-17

Inquest into the death of Alexandria Catherine Forrester

39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…

A 39-year-old woman with opioid dependency died from cardiac arrest caused by methadone toxicity. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatmen…

addiction medicinegeneral practicediagnosticmedicationmethadone
VIChospital2025-10-17

Finding into death of Raymond Charles Levy

75y · Male·Aspiration pneumonia in the setting of epilepsy and cerebral palsy

Raymond Charles Levy, a 75-year-old man with cerebral palsy and epilepsy living in supported disability accommodation, died from aspiration pneumonia. He presented to hospital with fatigue, fever and cough on 18 October …

general medicineemergency medicineceftriaxone
VIChospital2025-10-17

Finding into death of Rachel Frances Piskun

42y · Female·Pneumonia, underlying severe cerebral palsy

Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…

emergency medicinegeneral medicinediagnosticmedicationmorphine
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