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SAcommunityNew2026-08-21

Coroner's Finding: Holden, Richard Arthur

74y · Male·Pulmonary thromboembolism due to right deep vein thrombosis

Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond t…

general practiceemergency medicinediagnosticdelaysalbutamol
SAhospital2026-08-13

Coroner's Finding: Josipovic, Petar

62y · Male·multi-organ failure on a background of aortic regurgitation and ischaemic heart …

A 62-year-old man with aortic regurgitation and coronary artery disease died from multi-organ failure after emergency cardiothoracic surgery. His elective surgery was cancelled twice (14 and 22 Aug 2023) due to prioritiz…

cardiothoracic surgerycardiologycommunicationsystem
ACTmental health2026-08-12

Inquest into the death of Ms UT

37y · Female·morbid obesity with dilated cardiomyopathy and obstructive sleep apnoea

Ms UT, a 37-year-old woman with treatment-resistant schizophrenia, died of morbid obesity with dilated cardiomyopathy and obstructive sleep apnoea. She was prescribed clozapine, an effective but potentially cardiotoxic a…

psychiatrycardiologyclozapine
TASaged careNew2026-08-10

Coroner's Finding: Cox, Beverley Jane

88y · Female·Cardiac failure secondary to pacemaker failure and pacemaker battery exhaustion

This case involves an 88-year-old woman with a pacemaker who became lost to follow-up after her last clinic visit in May 2019, when no follow-up appointment was arranged. Without systematic tracking between the specialis…

cardiologygeneral practicesystemcommunication
NSWhome2026-08-10

Inquest into the death of SMS

14y · Female·unascertained natural causes – possibly encephalitis leading to seizure or sudde…

SMS, a 14-year-old previously healthy girl, collapsed unexpectedly at home on 10 October 2021 and was found unresponsive and not breathing. Immediate resuscitation was commenced by family members and emergency services, …

emergency medicineintensive care
VIChospital2026-07-27

Finding into death of Alan Gordon Wolstenholme

72y · Male·Complications of suspected upper gastrointestinal tract haemorrhage, hospital ac…

A 72-year-old man with metastatic squamous cell lung cancer and multiple serious comorbidities was admitted to Ballarat Hospital in July 2024 with lethargy, fatigue, and rapid atrial fibrillation. Due to medication chart…

cardiologyemergency medicinemedicationsystembuprenorphine
QLDhospital2026-07-17

Inquest into the death of Thea Flaskett

<1y · Female·Transposition of the Great Arteries

Thea Flaskett was born at Redcliffe Hospital on 11 September 2023 with undiagnosed transposition of the great arteries (TGA), a critical congenital heart defect requiring urgent diagnosis and specialist intervention. She…

obstetricspaediatrics
SAhospital2026-07-14

Coroner's Finding: Rosenzweig, Colin Anthony

61y · Male·bronchopneumonia complicating cerebrovascular accident due to cardioembolism on …

A 61-year-old man with a mechanical aortic valve underwent colonoscopy requiring temporary warfarin cessation. Following the procedure, he was discharged with a plan to recommence warfarin but without clear postoperative…

general surgerycardiologymedicationcommunicationwarfarin
SAhome2026-07-13

Coroner's Finding: Low, David John

64y · Male·ischaemic and hypertensive heart disease (operated) with cardiomegaly with contr…

A 64-year-old man with ischaemic heart disease, cardiomegaly, diabetes and obesity died at home from cardiac failure after calling his care worker for assistance. A paramedic arrived but refused to force entry, instead a…

cardiologyparamedicinesystemdelay
QLDhospital2026-07-07

Inquest into the death of Christopher Doughty

67y · Male·Multi-organ failure secondary to acute myocardial infarction secondary to in-ste…

Christopher Doughty, 67, was admitted to Hervey Bay Hospital on 17 September 2021 with a life-threatening gastrointestinal bleed two months after receiving coronary stents. The bleed was likely caused by dual antiplatele…

cardiologyemergency medicinecommunicationproceduralaspirin
QLD2026-07-07

Inquest into the death of Clifford Raymond Grogan

68y · Male·Atherosclerotic cardiovascular disease

Clifford Raymond Grogan, a 68-year-old First Nations man, died from atherosclerotic cardiovascular disease while in custody at Lotus Glen Correctional Centre on 11 May 2023. He had significant pre-existing cardiac diseas…

cardiologygeneral medicine
VIChome2026-06-29

Finding into death of Heather Joy Harris

61y · Female·Unascertained (natural causes)

Ms Harris, aged 61, with intellectual disability, autism spectrum disorder, and multiple medical conditions (including aortic regurgitation, hypothyroidism, dyspnoea, hyperlipidaemia, and obesity), was living in supporte…

general practicecardiologysertraline
NSWhospital2026-06-24

Inquest into the death of Alan Frederick Cornish

77y · Male·Congestive cardiac failure with an antecedent cause of ischaemic cardiomyopathy …

Alan Frederick Cornish, aged 77, died in lawful custody at Long Bay Hospital on 1 September 2025 from congestive cardiac failure with ischaemic cardiomyopathy, complicated by chronic kidney disease, COPD, and type 2 diab…

cardiologygeriatric medicineremdesivir
VIChome2026-06-19

Finding into death of Elizabeth Jean Hanlon

38y · Female·Pulmonary thromboembolism secondary to deep venous thrombosis due to promethazin…

Elizabeth Jean Hanlon, aged 38, died from pulmonary thromboembolism secondary to deep venous thrombosis following a promethazine overdose. She had complex mental health diagnoses including borderline personality disorder…

psychiatryintensive carepromethazine
SA2026-06-02

Coroner's Finding: Taylor, Nathan James

40y · Male·Unascertained

Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…

cardiologygeneral medicinediagnosticsystempaliperidone
NSWhospital2026-06-01

Inquest into the death of Michael Anthony Guider

73y · Male·Thromboembolism on a background of a spindle cell tumour

Michael Anthony Guider, aged 73, was an inmate in NSW correctional custody when he developed progressive shortness of breath and lower limb swelling. He presented to Prince of Wales Hospital on 6 September 2024 and was f…

cardiologycorrectional health
NSWhospital2026-05-15

Inquest into the death of Robert Bell-Williams

71y · Male·metastatic papillary renal cell carcinoma

Robert Bell-Williams, aged 71, died from metastatic papillary renal cell carcinoma while in lawful custody at Long Bay Hospital on 1 February 2024. Imprisoned since 2012, he was diagnosed with renal cell carcinoma in 202…

oncologypalliative carecabozantinib
VICcommunity2026-05-14

Finding into death of A Q

61y · Male·Ischaemic heart disease secondary to coronary artery atherosclerosis

AQ, a 61-year-old motorsport racer, died from ischaemic heart disease secondary to coronary artery atherosclerosis while competing at Phillip Island Grand Prix Circuit on 23 November 2024. In April 2024, he underwent ste…

cardiologygeneral practicecommunicationprocedural
VIChome2026-04-30

Finding into death of Nick Panagiotopoulos

47y · Male·Acute myocardial infarction due to thrombotic occlusion of the right coronary ar…

Nick Panagiotopoulos, a 47-year-old man, suffered a fatal acute myocardial infarction (heart attack) on 16 October 2021 at home in Preston, Victoria. His family made five calls to Triple Zero (000) requesting emergency a…

cardiologyemergency medicinesystemdelay
VIChospital2026-04-28

Finding into death of Ronald William Beaumont

74y · Male·Acute myocardial infarction complicated by multiple organ failure

Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…

cardiologyorthopaedic surgerymedicationcommunicationaspirin
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