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QLDaged care2026-01-15

Inquest into the death of Steven Thelander

29y · Male·Ketoacidosis as a consequence of diabetes mellitus (Type 1)

Steven Thelander, aged 29, died from ketoacidosis due to poorly controlled Type 1 diabetes while in residential disability support care at Multicap. He had cerebral palsy with severe intellectual impairment and epilepsy …

general practiceendocrinologydiagnosticcommunicationinsulin
VIChospital2025-12-08

Finding into death of Jamie Lee Argent

38y · Male·Diabetic ketoacidosis secondary to pyelonephritis in a man with insulin dependen…

A 38-year-old man with insulin-dependent diabetes, partial blindness, gastroparesis, seizures, chronic kidney disease and peripheral vascular disease died from diabetic ketoacidosis precipitated by pyelonephritis. He had…

emergency medicineendocrinologylamotrigine
NSW2025-09-15

Inquest into the death of Robert Sievers

81y · Male·COVID-19 infection on a background of Type 2 Diabetes and end stage chronic kidn…

Robert Sievers, an 81-year-old man incarcerated since 2001, died from COVID-19 infection on a background of type 2 diabetes and end-stage chronic kidney disease. Despite multiple warnings about vaccination, Sievers refus…

geriatric medicinepalliative careantiviral medication
NSWhospital2025-08-14

Inquest into the death of Wilfred Whippy Williams

45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia

A 45-year-old Aboriginal man with poorly managed diabetes and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs i…

emergency medicineendocrinologycommunicationdiagnosticmetformin
VIChospital2025-07-28

Finding into death of Juvetta Pedruco Columbine

47y · Female·Aspiration pneumonia in the setting of type 1 diabetes mellitus, previous cerebr…

A 47-year-old NDIS participant with a history of stroke, diabetes, and complex comorbidities died from aspiration pneumonia at Austin Hospital. She had been living in specialist disability accommodation with support serv…

infectious diseasesrespiratory medicine
VIChome2025-07-24

Finding into death of Jill Hughes

75y · Female·Infective complications of a left hand injury with diabetic ketoacidosis

A 75-year-old woman died from infective complications of a left hand wound sustained in a fall from a ladder in November 2023, complicated by undiagnosed diabetic ketoacidosis. Despite family encouragement to seek medica…

infectious diseasesendocrinologydelaydiagnostic
QLDhospital2025-05-26

Findings into the death of Trevor Charles Stone

57y · Male·Metastatic lung adenocarcinoma (stage IVA non-small cell lung cancer)

Trevor Charles Stone, a 57-year-old First Nations man imprisoned for sexual offences, died from metastatic lung adenocarcinoma with contributing comorbidities (diabetes, hypertension, dyslipidaemia, ischaemic heart disea…

oncologypalliative carecarboplatin
NSWmental health2025-03-28

Inquest into the death of NL

62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval

NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with …

psychiatryendocrinologydiagnosticcommunicationthyroxine
TAShome2024-10-23

Coroner's Finding: Earl, Kathleen May

58y · Female·Complications of poorly controlled type 2 diabetes

Ms Kathleen Earl, aged 58, died from complications of poorly controlled type 2 diabetes in June 2022. She had an intellectual disability and received support from IHCS (Individual Support Worker) since 2005. Critical def…

general practiceendocrinologysystemcommunicationryzodeg
QLDhospital2024-10-18

Findings into the death of John Ainsworth

68y · Male·Cerebrovascular disease

John Raymond Ainsworth, a 68-year-old prisoner, died of cerebrovascular disease following a severe stroke on 25 November 2020. He had poorly controlled Type II diabetes, hypertension, and high cholesterol. Prior to his a…

neurologyemergency medicinedelaymetformin
WAhospital2024-09-24

Inquest into the death of Raymond Sydney CHEEK

89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…

Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarin…

emergency medicineendocrinologymedicationsystemryzodeg insulin
VIChome2024-08-29

Finding into death of A S

19y · Female·sodium nitrite toxicity

This finding concerns the death of a 19-year-old transgender woman (referred to as 'AS') who died from sodium nitrite toxicity on 9 May 2021. She ingested sodium nitrite during a video call with a friend in NSW. AS had a…

psychiatryendocrinologysystemsodium nitrite
VIChome2024-08-29

Finding into death of Natalie Wilson

33y · Female·neck compression and hanging

Natalie was a 33-year-old transgender woman with a long history of mental health conditions including severe social anxiety, agoraphobia, borderline personality disorder and PTSD, with suicidal ideation since age 17 and …

psychiatrypsychologysystemescitalopram
NSW2024-06-20

Inquest into the death of Michael Baker

44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…

Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…

general practicepsychiatrydiagnosticcommunicationmethadone
VICcommunity2023-12-20

Finding into death of Lachlan McMahon Cook

16y · Male·Hypoxic/ischaemic encephalopathy in the context of diabetic ketoacidosis

A 16-year-old with Type 1 Diabetes died from diabetic ketoacidosis (DKA) precipitated by acute gastroenteritis acquired while on a school trip to Vietnam. Despite reporting vomiting at 8am on 26 September 2019, Lachlan w…

endocrinologygeneral practicediagnosticcommunicationinsulin
TAScommunity2023-11-02

Coroner's Finding: Mellor, Alyson Margaret

64y · Female·head injury sustained in a single motor vehicle accident

Mrs Alyson Margaret Mellor, aged 64, died from a head injury sustained in a single-vehicle motor accident on 30 April 2022. She had type 1 diabetes managed with an insulin pump, and on the day of the accident her husband…

endocrinologygeneral practiceinsulin
TAShospital2023-09-12

Coroner's Finding: Harris, Peter Blackwell

75y · Male·pneumonia and head injury from fall

Peter Harris, aged 75, was admitted with behavioural disturbance and hyponatraemia (low serum sodium of 124 mmol/L). Initial clinical assessment did not identify falls risk. After 4 days, he fell backwards suddenly while…

general medicinegeriatric medicinediagnosticquetiapine
QLDhospital2023-06-26

Searle, William Edward

74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …

William Searle, a 74-year-old prisoner, died from aspiration of gastric contents following a Whipple procedure for recurrent ampullary adenoma. The clinical lessons involve recognition of gastroparesis risk in high-risk …

general surgeryintensive carediagnosticcommunicationadrenaline
TAShospital2023-05-31

Coroner's Finding: Richardson Rebecca Eileen

29y · Female·acute myocardial infarction due to stenotic coronary vessel (left anterior desce…

Rebecca Richardson, a 29-year-old with type 1 diabetes and coronary artery disease, died of acute myocardial infarction on 7-9 May 2019. She presented to NWRH ED on 6 May with abdominal pain and vomiting, initially attri…

emergency medicinecardiologydiagnosticcommunicationinsulin
TAShospital2023-02-17

Coroner's Finding: Hanslow, Rodney James

86y · Male·progressive cognitive decline/decompensation and gastrointestinal haemorrhage

An 86-year-old man with Parkinson's disease and long-standing gastro-oesophageal reflux disease (GORD) sustained a traumatic brain injury from a fall at home on 3 July 2021. He was admitted to hospital on 6 July 2021 wit…

general medicinegastroenterologymedicationdiagnosticproton pump inhibitor

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