Coronial
VIChospital2022-07-07

Finding into death of K LW

76y · Male·complications of acute myeloid leukaemia

…laparoscopic cholecystectomy, the underlying haematological malignancy was not identified until post-mortem bone biopsy. He deteriorated rapidly in ICU and died on 19 August 2021. The coroner found that custodial and hea…

haematologyintensive care
NSW2018-02-09

Inquest into the death of Ian James McAuliffe

67y · Male·metastatic prostate cancer

Ian McAuliffe, a 67-year-old man serving a custodial sentence, died from metastatic prostate cancer. The case examined whether his cancer treatment as a prisoner was adequate compared to community care. His oncologist Dr…

oncologypalliative caregoserelin
SA2009-06-03

Coroner's Finding: GROOTVELD Gerard

75y · Male·disseminated carcinoma of the prostate gland

Gerard Grootveld, a 75-year-old prisoner, died from disseminated prostate cancer with bone metastases. Sentenced in July 2006 despite known advanced cancer and multiple comorbidities, his health rap…

palliative carecorrectional health
VIC2011-07-21

Finding into death of Cherie Deanne Alderson

42y · Female·Metastatic breast cancer

Cherie Alderson, aged 42, died from metastatic breast cancer at a hospice after progressive deterioration. She had cerebral palsy from infancy and lived in Department of Human Services care for 42 years. Diagnosed with b…

oncologypalliative care
WAhospital2008-02

Inquest into the Death of Evans

45y · Female·Extensive retroperitoneal haemorrhage following bone marrow biopsy procedure wit…

…atosis type 1, essential thrombocytosis, prior cancers, and recent cerebral infarcts on warfarin, underwent bone marrow biopsy at Royal Perth Hospital on 23 November 2004 to investigate her thrombocytosis and exclude leu…

haematologygeneral medicinewarfarin
SA2013-02-13

Coroner's Finding: NYLANDER Harry Richard

58y · Male·metastatic multiple myeloma

…medical review by a senior medical oncologist concluded that while there was a 2-3 week delay in initial CT scanning in 2004, earlier diagnosis would not have prevented death. The disease was disseminated and advanced at…

oncologyhaematologydelay
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back …

emergency medicineintensive carediagnosticproceduralhydromorphone
NSWhospital2015-02-17

Inquest into the death of Neal Richardson

48y · Male·large cell carcinoma of lung with metastases

…al. He had presented to prison health services in May-June 2014 with pain attributed to kidney stones. A CT scan on 27 April 2014 showed renal calculi; a subsequent CT on 23 June revealed rapidly progressive metastatic d…

palliative careoncologydiagnosticmethadone
VIChospital2022-03-09

Finding into death of Daniel McQuilken

68y · Male·Lung cancer

Daniel McQuilken, a 68-year-old man in immigration detention, died from metastatic lung cancer. His lung cancer diagnosis was made while detained, likely related to his significant smoking history and prior asbestos and …

oncologyrespiratory medicinechemotherapy agents
QLDhospital2009-12-03

Heywood, John Martin

68y · Male·Abnormal heart rhythm (arrhythmia) precipitated by coronary atherosclerosis and …

John Martin Heywood, a 68-year-old prisoner, died of natural causes (arrhythmia precipitated by coronary atherosclerosis and phaeochromocytoma) while in custody at the Princess Alexandra Hospital Secure Unit. He had been…

cardiologyendocrinology
QLDhospital2015-01-29

Carpenter, Harold James

66y · Male·Coronary atherosclerosis with emphysema as secondary cause

Harold James Carpenter, a 66-year-old prisoner with significant comorbidities including ischaemic heart disease, emphysema, hepatitis C and possible malignancy, died from coronary atherosclerosis and emphysema. He presen…

emergency medicineorthopaedic surgeryoxycodone
NThospital2021-01-07

Inquest into the death of Edgar Forrester

56y · Male·aspiration pneumonitis secondary to airways obstruction from squamous cell carci…

…lties were documented but endoscopy not arranged until February 2020, despite symptoms from September. A CT scan ordered in November was cancelled inappropriately. The diagnosis was ultimately made in December 2019 on in…

general practicecardiologydiagnosticdelay
QLDhospital2019-06-20

Lawless-Pyne, Timothy Paul

57y · Male·Bleeding oesophageal varices due to cirrhosis and metastatic hepatocellular carc…

A 57-year-old prisoner with hepatitis C, cirrhosis, and advanced hepatocellular carcinoma died from bleeding oesophageal varices. He was appropriately managed with aggressive treatment including TACE and variceal ligatio…

gastroenterologyhepatologymorphine
SAhospital2020-06-18

Coroner's Finding: BOYCE Ian Charles

85y · Male·hospital acquired pneumonia on a background of metastatic colorectal carcinoma

…l with psychotic depression, suicidal ideation, and severe malnutrition after two years of depression. A CT scan revealed previously undetected metastatic colorectal cancer. He rapidly deteriorated with fever, hypoxia, a…

psychiatrygeriatric medicine
SA2025-11-14

Coroner's Finding: Porter, Peter Raymond

65y · Male·metastatic prostate cancer complicated by deep vein thromboses

Peter Raymond Porter, aged 65, died in prison from metastatic prostate cancer complicated by deep vein thromboses in January 2022, eight and a half years after diagnosis. He had presented with urinary symptoms in Decembe…

oncologyurologyduodart
WAhospital2021-08-06

Inquest into the Death of Alex Carl MILLS

76y · Male·Sepsis, with osteomyelitis and infective endocarditis

Alex Mills, a 76-year-old sentenced prisoner with complex medical history including atrial fibrillation, valvular heart disease, and rheumatoid arthritis, died from sepsis caused by osteomyelitis and infective endocardit…

infectious diseasescardiologydiagnosticdelayprednisolone
VIChospital2024-04-11

Finding into death of Mark Andrew Spillane

58y · Male·Septic shock secondary to intra-abdominal collections as sequelae of osteomyelit…

…tra-abdominal collections caused by osteomyelitis/discitis of the spine. He initially presented with a foot bone infection detected on imaging in May 2023. Subsequent imaging revealed large bilateral psoas and retroperit…

infectious diseasesgeneral medicine
TAShospital2025-04-23

Coroner's Finding: Dow, Vicki Elizabeth

69y · Female·Multiple organ failure due to secondary haemochromatosis (transfusion-associated…

Mrs Vicki Dow, 69, died from multiple organ failure secondary to iron overload (transfusion-associated haemochromatosis) from treatment of myelodysplastic syndrome. She had declined iron chelation therapy for 19 months d…

haematologyemergency medicinecommunicationdiagnosticiron chelation therapy
NSW2021-10-12

Inquest into the death of Donald GREENAWAY

88y · Male·Metastatic prostate carcinoma

Donald Victor Greenaway, an 88-year-old man serving a 21-year prison sentence, died from metastatic prostate carcinoma in the Aged Care Ward at Long Bay Correctional Centre. He had been diagnosed with stage IV prostate c…

oncologyradiation oncologyandrogen deprivation therapy
VICaged care2018-11-29

Finding into death of Nikolaos Margelis

82y · Male·Traumatic head injury due to head striking the floor

An 82-year-old man with Alzheimer's dementia residing in a secure aged care facility died from traumatic head injury sustained when he was pushed by another resident during an interaction in a hallway. The deceased had a…

psychiatryemergency medicinequetiapine

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