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VICaged care2026-05-06

Finding into death of Cornelia Groot

87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…

An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…

geriatric medicineemergency medicinediagnosticcommunicationoxycodone
VIChospital2026-04-16

Finding into death of Damien Mark Stone

53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures

Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…

emergency medicineneurologydiagnosticcommunicationoxycodone
VIChome2026-04-14

Finding into death of James Thomas Reilly

86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall

James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…

emergency medicinegeneral medicinediagnosticmedicationenoxaparin
QLDhospital2026-03-06

Non-inquest findings into the death of Ms B

35y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to vertebro…

A 35-year-old woman presented to a rural hospital with a three-day history of collapses, slurred speech, vomiting, and abnormal eye movements. A non-contrast CT head scan was normal, and she was discharged with a diagnos…

emergency medicinegeneral practicediagnosticcommunication
VIChome2026-02-17

Finding into death of Laurence Mark O'brien

22y · Male·Mixed drug toxicity (tapentadol, clonazepam, citalopram, amphetamine, olanzapine…

Laurence O'Brien, a 22-year-old with acquired brain injury from a childhood motor vehicle accident, died from mixed drug toxicity involving eight substances including prescribed opioids, benzodiazepines, and unprescribed…

general practicepsychiatrymedicationsystemtapentadol
NTcommunity2026-01-23

Inquest into the death of Kumanjayi Johnson

45y · Male·Environmental exposure and dehydration

A 45-year-old Aboriginal man with severe cognitive impairment (6.5-year-old equivalent English comprehension), traumatic brain injury, epilepsy and multiple medical conditions died from environmental exposure and dehydra…

geriatric medicinepsychiatrycommunicationsystem
VIChospital2026-01-08

Finding into death of Linette Ann Hawkins

80y · Female·Injuries sustained in a motor vehicle collision (driver)

An 80-year-old woman died from injuries sustained in a motor vehicle collision after likely experiencing a seizure or similar medical episode while driving. She had a history of traumatic brain injury from 1972 and a doc…

neurologytrauma surgerycommunicationsystemlevothyroxine
NSWhospital2025-12-19

Inquest into the death of JBO

27y · Female·Cardiac arrhythmia (first confirmed as ventricular fibrillation) of unascertaine…

A 27-year-old Aboriginal woman suffered sudden cardiac arrhythmia (ventricular fibrillation) immediately after recording video evidence of a suspected breach of her protective apprehended personal violence order (APVO). …

emergency medicinecardiologycommunicationsystemamiodarone
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
SAcommunity2025-10-17

Coroner's Finding: Hall, Robert Lloyd

66y · Male·multiple injuries sustained in motor vehicle collision

A 66-year-old cyclist was struck and killed from behind by a driver with left absolute homonymous hemianopia (left-sided visual field loss) who was not scanning to compensate for his disability. The driver had suffered a…

neurosurgeryneurologysystemcommunication
VICaged care2025-10-10

Finding into death of Christopher Kuric

52y · Male·Aspiration pneumonia in a man with end stage Huntington's disease

Christopher Kuric, a 52-year-old man with end-stage Huntington's disease residing in specialist residential care, died of aspiration pneumonia. He had documented swallowing difficulties managed by speech pathology and di…

neurologypalliative carepossibly_preventabledelay
VIChospital2025-10-10

Finding into death of Jeffrey George Nirens

70y · Male·intracranial haemorrhage secondary to haemorrhagic transformation of ischaemic s…

A 70-year-old man with chronic small vessel cerebral ischaemia died from intracranial haemorrhage following haemorrhagic transformation of an ischaemic stroke while in prison custody. He presented with acute stroke sympt…

neurologyemergency medicinemedicationsystemenoxaparin
QLDhospital2025-10-08

Inquest into the death of Janis Ellen Doherty

57y · Female·Multi-organ failure due to drug-induced liver injury caused by sodium valproate …

Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nau…

neurologyhepatologydiagnosticmedicationsodium valproate
NSWhome2025-09-11

Inquest into the death of H GM

0y · Female·Unascertained

A 9-month-old girl died suddenly on 23 July 2018 following multiple head injuries from blunt force trauma sustained shortly before death. She had presented to medical practitioners multiple times in the preceding weeks w…

paediatricsemergency medicinediagnostic
VIChospital2025-08-21

Finding into death of Andrew William Barr

54y · Male·Complications of pelvic and spinal fractures sustained in a fall in man with Dow…

Andrew William Barr, a 54-year-old man with Down syndrome and Alzheimer's dementia, died from complications of pelvic and spinal fractures sustained in a fall. Following his mother's death in January 2021 and his Februar…

orthopaedic surgerypalliative carecommunicationsystemanti-epileptic medication
VIChospital2025-08-18

Finding into death of B T

53y · Male·Complications of hypoxic brain injury secondary to mixed drug toxicity (methylam…

BT, a 53-year-old man with substance use disorder and mental health conditions, died from complications of hypoxic brain injury secondary to mixed drug toxicity (methylamphetamine, benzodiazepines, metonitazene). He inje…

emergency medicineintensive caremethamphetamine
VIChospital2025-07-30

Finding into death of MHT

86y · Male·Complications of blunt force trauma in a man with cardiac amyloidosis and athero…

An 86-year-old man with dementia, cardiac amyloidosis and atherosclerotic cardiovascular disease died from complications of blunt force trauma sustained in an assault by his adult son. The deceased had been diagnosed wit…

emergency medicineneurosurgerysystemcommunicationondansetron
TASaged care2025-05-26

Coroner's Finding: de-identified GJ

94y · Male·aspiration pneumonia due to stroke following surgery to repair fracture of neck …

A 94-year-old man with dementia died from aspiration pneumonia following a stroke after hip surgery. The stroke and hip fracture resulted from being pushed by another resident with Alzheimer's dementia at an aged care fa…

geriatric medicineorthopaedic surgerysystemdelayoxazepam
ACThospital2025-04-09

Inquest Into The Death Of Peter Hanisch

69y · Male·thoracic aortic aneurysm with dissection

Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…

radiologyemergency medicinediagnosticsystem
NTcommunity2025-04-04

Inquest into the death of Kailab

15y · Male·multiple injuries caused by a motor vehicle accident

Kailab Moir, a 15-year-old Aboriginal boy with FASD, complex trauma, and ADHD, died in a single-vehicle rollover while a passenger in a stolen vehicle. He had been in out-of-home care since age 5 with approximately 35 di…

paediatricspsychiatrydiagnosticsystemalcohol
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