Coronial
VICcommunity2023-07-28

Finding into death of Marcus William Caldwell

27y · Male·Hanging

…th medication, Marcus developed significant workplace stress from December 2017 onwards, characterised by burnout, fatigue, and moral distress—feeling unable to provide adequate animal care due to understaffing. His emo…

psychiatrygeneral practicesystemcommunicationclozapine
WA2015-06-02

Inquest into the Death of Justin Aaron KING

36y · Male·Multiple injuries from motorcycle collision

…ntersection of Great Eastern Highway and Bullarra Road, Greenmount, Western Australia. He had performed a burnout in the carpark of the Pig & Whistle Tavern in Swan View, attracting police attention. When police activat…

alcohol
VIChome2017

Finding into death of Harold George Nolan

73y · Male·Stab wound to the neck

…sons include the need for regular follow-up after initiating antidepressants, better recognition of carer burnout as a mental health risk factor, and more timely escalation of care when psychotic symptoms emerge.

general practicepsychiatrycommunicationdelayantidepressants
WAhospital2005-12-13

Inquest into the Death of Peter Daryl Samson

20y · Male·Pelvic Injury

Peter Daryl Samson, a 20-year-old Aboriginal male, died from a pelvic fracture sustained in a motor vehicle rollover on 22 September 2003. He was brought to Derby Regional Hospital where he was assessed briefly by nursin…

emergency medicinegeneral practicediagnosticdelayalcohol
VIChome2012-02-14

Finding into death of David Travaglia

27y · Male·carbon monoxide poisoning

David Travaglia, a 27-year-old man with cerebral palsy, profound deafness, and inability to walk or speak, died from carbon monoxide poisoning. He was killed by his father, Edo Travaglia, who deliberately connected a hos…

benzodiazepines
VIC2020

Finding into death of Stephen Myall

59y · Male·Hanging

Stephen Myall, a 59-year-old magistrate, died by hanging in March 2018. He was a dedicated judicial officer with exceptional work ethic but experienced significant occupational stress from increasing court workloads (up …

NSWhome2015-10-29

Inquest into the death of Noreen PEACOCK

83y · Female·undetermined (likely hypothermia based on clinical findings)

An 83-year-old woman with advanced Alzheimer's and vascular dementia died alone at home between April-August 2013. The coroner found the direct cause undetermined (likely hypothermia) but highlighted critical preventable…

geriatric medicinegeneral practicedelaycommunicationatorvastatin
VICcommunity2020-11-06

Finding into death of Jessica Morgana Wilby

45y · Female·Compression of the neck in circumstances of hanging

Jessica Morgana Wilby, aged 45, a highly accomplished Principal In House Solicitor at the Coroners Court of Victoria with extensive qualifications and excellent performance record, took her life by hanging on 7 September…

psychiatrypsychologysystemcommunicationantidepressants
NThome2010-01-19

Inquest into the death of Deborah Leanne Melville

12y · Female·acute septicaemia resulting from osteomyelitis of the left femur

A 12-year-old Aboriginal girl died from septicaemia caused by untreated osteomyelitis of the left femur. Three weeks after a sports injury, despite evidence of severe and deteriorating illness including inability to walk…

orthopaedic surgeryinfectious diseasesdiagnosticsystem
SAhospital2018-03-05

Coroner's Finding: HOWARD Miranda Robyn and MCPHERSON-SMITH Aurora Holly Violet

Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…

Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following overdose; Aurora McPherson-S…

psychiatrypsychologydiagnosticcommunicationquetiapine

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