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VIChome2026-03-04

Finding into death of Carol Fay Slade

54y · Female·Severe burns sustained in a house fire (palliated)

Carol Fay Slade, a 54-year-old woman with acquired brain injury from a 2003 motorcycle accident and mobility limitations, died from severe burns sustained in a house fire at her public housing property in Shepparton. The…

emergency medicineintensive caresystemmethadone
TAShome2026-02-17

Coroner's Finding: Gregory and Diane Burkhalter

73y · Male·Gregory Frank Burkhalter: carbon monoxide toxicity due to inhalation of carbon m…

Two elderly US-born residents died in a house fire caused by a 120-volt electric blanket operating on Australia's 230-volt grid, resulting in insulation failure and combustion. Mr Burkhalter (73) died from carbon monoxid…

emergency medicineanaesthesiasystem
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
QLDhospital2025-03-14

Non-inquest findings - a 5 year old boy

5y · Male·Complications of burns

A 5-year-old boy died from complications of severe burns sustained during a fuel ignition incident at his father's rural property. While refuelling a small motorcycle, the father failed to shut off the engine and did not…

plastic and reconstructive surgeryintensive careprocedural
QLDaged care2024-10-10

Non-inquest findings into the death of Diane Margaret Crowther

76y · Female·multiple organ failure due to abdominal wall cellulitis (surgically treated)

Mrs Crowther, a 76-year-old obese woman with multiple comorbidities in residential aged care, died from multiple organ failure secondary to abdominal wall cellulitis. A critical care failure occurred when an old dressing…

geriatric medicineplastic and reconstructive surgerydiagnosticcommunicationhydrozole cream
VIChospital2024-09-26

Finding into death of FH C

11y · Male·Sepsis

An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…

emergency medicinepaediatricsdiagnosticcommunicationrisperidone
NSWhospital2023-10-31

Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…

Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…

intensive careanaesthesiadiagnosticproceduralrocuronium
VIChospital2023-07-06

Finding into death of Michael Alan Holmes

34y · Male·effects of burns

Michael Holmes, 34, died from severe burns sustained when he re-entered a burning house attempting to rescue his son. The fire originated from clothes and towels left drying on a rack in front of an unattended wood heate…

emergency medicinetrauma surgerysystemfentanyl
QLDcommunity2023-04-05

Grimes, William George

31y · Male·Burns

31-year-old George Grimes with longstanding schizophrenia was found threatening self-immolation after consuming alcohol and missing antipsychotic medication. Despite police de-escalation attempts, he doused himself with …

psychiatryemergency medicinediagnosticcommunicationquetiapine
TAShome2022-08-04

Coroner's Finding: Joyce. Kaye Maree

58y · Female·thermal burns

A 58-year-old woman with schizophrenia died from extensive thermal burns after a fire originated in a wall-mounted heat pump that lacked a required residual current device (RCD). The heat pump was installed in 2012 witho…

psychiatrygeneral practicesystempaliperidone
QLDhospital2022-07-08

R - Non-inquest findings

0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…

A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…

anaesthesiaintensive carediagnosticproceduralpropofol
VIChome2022-05-03

Finding into death of Carol Austin

65y · Female·Plastic bag asphyxia

Carol Austin, 65, died by plastic bag asphyxia at her home in Wangaratta in August 2018. She had a 20-year history of depression and had recently experienced suicidal ideation, a suicide attempt, and burns injury requiri…

psychiatrygeneral practicesystemcitalopram
VIC2022-03-21

Finding into death of Nilofer Nezami

38y · Female·Unascertained

Nilofer Nezami, a 38-year-old Victorian resident, died on 7 January 2019 following cosmetic surgery in Iran. She underwent multiple procedures including eye, breast, arm and abdominal surgery. Post-operatively, she devel…

plastic and reconstructive surgeryanaesthesiasystemproceduralmorphine
QLDhospital2021-11-01

Masoumali, Omid

24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns

Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement.…

plastic and reconstructive surgeryintensive carecommunicationsystem
QLDcommunityPodcast2020-06-26

Nyholt, Nicole Sonia and Clark, Margaret Louisa

Female·Burns due to gas explosion due to motor vehicle collision with building

A 60-year-old man with a long-standing history of seizures experienced an epileptic seizure while driving and lost control of his vehicle. It collided with an LPG gas cylinder outside a café, triggering an explosion that…

emergency medicineneurologycommunicationsystem
NSWhospital2020-01-31

Inquest into the death of OS

5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …

A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…

plastic and reconstructive surgeryanaesthesiamedicationproceduralmorphine
NSWhome2019-10-04

Inquest into the death of C D

60y · Male·burn wounds and the consequences thereof

CD, a 60-year-old man with long-standing psychiatric history (schizophrenia/schizoaffective disorder) and alcohol use disorder, set his house alight on 19 September 2017 after becoming acutely unwell with paranoid ideati…

general practicepsychiatrydiagnosticcommunicationdiazepam
NSWaged care2019-09-27

Inquest into the death of Epenesa PAHIVA

87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…

Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (h…

dermatologygeneral practicediagnosticcommunicationbleach
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
ACThome2019-06-04

Inquest into the death of Lauren Maree Johnstone

48y · Female·Combined toxic effect of prescription and non-prescription medications including…

Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…

general practicesurgerycommunicationsystemdoxylamine

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