Coronial
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NSW2026-05-20

Inquest into the death of Mr Edward Curic aka Grahovac

49y · Male·Diabetes Mellitus and the Consequences thereof

Mr Edward Curic (49) died at Long Bay Correctional Complex on 21 May 2022 from diabetes mellitus and complications. He had poorly controlled Type 2 diabetes for 30 years with severe complications including bilateral ampu…

correctional healthgeneral medicinemethadone
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
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
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
NSWcommunity2022-08-02

Inquest into the disappearance and suspected death of Kenneth Klees

37y · Male·Unascertained

Kenneth Klees, aged 37, disappeared on 1 February 2021 and was found deceased on Mollymook beach on 26 February 2021. He had a history of depression, anxiety, poorly controlled type 2 diabetes, and obsessive-compulsive d…

general practicepsychiatrycommunicationsystem
NSW2021-11-30

Inquest into the death of Elias MELHEM

49y · Male·atherosclerotic and hypertensive cardiovascular disease, with type 2 diabetes me…

Elias Melhem, aged 49, died in custody from atherosclerotic and hypertensive cardiovascular disease with contributing type 2 diabetes. On 8 December 2019, he experienced chest pain at work but reported feeling better aft…

cardiologynephrologycommunicationinsulin
NSWPodcast2021-10-29

Inquest into the death of Jesse DRABSCH

31y · Male·Hypoxic brain injury caused by the exogenous administration of insulin, resultin…

Jesse Drabsch, 31, died from hypoglycaemia after self-injecting insulin in a gym bathroom. A competitive bodybuilder using performance and image enhancing drugs (PIEDs), Jesse entered the bathroom at 5:30pm on 16 Novembe…

endocrinologytoxicologysystemproceduralinsulin
NSWhome2019-12-20

Inquest into the deaths of TC and SN

Female·Hanging

This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral…

paediatricspsychiatrycommunicationsystem
NSWhospital2019-12-19

Inquest into the death of Lesley ARNDELL

61y · Female·multi organ failure due to abdominal sepsis

Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery requ…

general surgeryintensive caremedicationcommunicationpiperacillin/tazobactam
NSWmental health2019-11-22

Inquest into the death of David Dungay

29y · Male·cardiac arrhythmia

David Dungay, a 29-year-old Aboriginal man with chronic schizophrenia, type 1 diabetes, and obesity, died on 29 December 2015 in Long Bay Hospital's Mental Health Unit while in custody. The immediate trigger was his refu…

psychiatryemergency medicineproceduralcommunicationmidazolam
NSWhospital2019-06-14

Inquest into the death of Melissa King

33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…

Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraem…

intensive careendocrinologydiagnosticcommunicationglycoprep
NSW2018-11-15

Inquest into the death of Kenneth Johnstone

79y · Male·Complications associated with metastatic colorectal carcinoma and diabetes melli…

Kenneth Johnstone, a 79-year-old prisoner with extensive comorbidities including metastatic colorectal cancer, diabetes, stage 4 chronic kidney disease, and osteomyelitis, died from cancer complications. He was appropria…

oncologypalliative caremorphine
NSWhospital2018-10-10

Inquest into the death of Craig Catley

32y · Male·sudden cardiac arrhythmia

Craig Catley, aged 32, died of sudden cardiac arrhythmia while in prison custody one day after discharge from Prince of Wales Hospital following neurosurgery for a pituitary tumour. The coroner found his hospital care wa…

neurosurgeryintensive careclonidine
NSWhospital2015-12-02

Inquest into the death of Jessica Martin

24y · Female·peri-myocarditis in the presence of sub clinical Addison's disease

Jessica Martin, 24 years old, died of peri-myocarditis in the presence of subclinical Addison's disease. She presented to the ED with chest pain on 30 June 2009 and was diagnosed with viral pleurisy without specific inve…

emergency medicineradiation oncologydiagnosticneurofen
NSWhospital2015-12-02

Inquest into the death of Dr Peter Domachuk

33y · Male·presumed fatal cardiac arrhythmia in the presence of coronary artery atheroscler…

Dr D., a 33-year-old physicist, was admitted to Hornsby Hospital on 27 December 2012 with abdominal pain, nausea, vomiting and joint pain. His presentation included hypotension (97/61), tachycardia (116/min), hyponatraem…

emergency medicinegeneral medicinecommunicationsystemdiclofenac
NSWhospital2014-09-26

Inquest into the death of AA

10y · Male·hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…

AA, a 10-year-old boy with morbid obesity and severe obstructive sleep apnoea, died from hypoxic brain injury after a cardiorespiratory arrest. He had been admitted to hospital in May 2008 with these diagnoses and was pr…

respiratory medicineendocrinologycommunicationsystemmethadone
NSWhospital2014-09-26

Inquest into the death of AA

10y · Male·Hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…

A 10-year-old boy with severe obstructive sleep apnoea and morbid obesity died from hypoxic brain injury following cardiorespiratory arrest. Despite repeated medical interventions and explicit warnings that his condition…

respiratory medicineendocrinologycommunicationsystemmethadone
NSWcommunity2014-01-31

Inquest into the death of Albert CONSTABLE

63y · Male·Multiple blunt force injuries and mechanical asphyxia

Albert Constable, a 63-year-old heavy vehicle driver, died when his truck suddenly swerved across the median strip and crashed into a building at approximately 11:30 PM on 23 May 2013. The coroner found no mechanical fau…

general practiceforensic medicinemirtazapine

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