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VIChomeNew2026-08-26

Finding into death of Judith Margaret Kerr

78y · Female·Multiple organ failure secondary to sepsis and renal failure due to bronchopneum…

A 78-year-old woman with cognitive impairment, depression, and complex care needs fell at home on 11 February 2022. Her sons delayed seeking medical help for 4 days, during which she developed aspiration pneumonia and wa…

emergency medicineintensive carecommunicationsystemmirtazapine
SAaged careNew2026-08-21

Coroner's Finding: Biermann, Hans

92y · Male·respiratory failure secondary to bilateral pleural effusions on a background of …

Hans Biermann, aged 92, died on 1 March 2023 following respiratory failure secondary to bilateral pleural effusions and rib fractures sustained in a fall at Regis Playford aged care facility on 23 February 2023. Mr Bierm…

geriatric medicineemergency medicine
VIChospitalNew2026-08-18

Finding into death of Susan Elizabeth Czudar

63y · Female·1a: Aspiration pneumonia in a woman with acquired brain injury, 1b: Cerebrovascu…

Susan Czudar, 63, died of aspiration pneumonia complicated by acquired brain injury from a 2017 subarachnoid haemorrhage and multiple strokes. Residing in NDIS-funded specialist disability accommodation, she was admitted…

neurosurgeryradiology
SAhome2026-08-12

Coroner's Finding: Sylvia, Kate Marie

32y · Female·cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage

Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. mis…

paramedicinegeneral medicinediagnosticcommunicationoral contraceptive pill
VICcommunity2026-08-12

Finding into death of Christine Maree Giliberto

57y · Female·Urosepsis due to an obstructing renal calculus in a woman with multiple comorbid…

Christine Giliberto, aged 57, died of urosepsis from an obstructing kidney stone. She lived in supported disability accommodation with severe lifelong disabilities (hydrocephalus, cerebral palsy, non-verbal). An obstruct…

general medicinepalliative care
VIChome2026-08-12

Finding into death of Janene Louise Weston

50y · Female·Intracranial haemorrhage (left frontoparietal intraparenchymal haemorrhage with …

Janene Louise Weston, a 50-year-old woman with acquired brain injury from autoimmune encephalitis and history of multiple strokes, died at home in specialist disability accommodation from an intracranial haemorrhage. She…

general medicineurologyapixaban
NSWmental health2026-08-11

Inquest into the death of Raeputa Tangatapoto

55y · Male·Unascertained natural causes

A 55-year-old man with chronic treatment-resistant schizophrenia died at Forensic Hospital while lawfully detained on 26 December 2024. He had presented to Prince of Wales Hospital on 17 December with chest pain, tachyca…

psychiatryforensic medicineclozapine
WAhome2026-08-04

Inquest into the Death of Paul Shen Vun WONG

40y · Male·Carbon monoxide toxicity

Paul Shen Vun Wong, a 40-year-old man with treatment-resistant schizophrenia and schizoaffective disorder, died from carbon monoxide toxicity at his Rockingham home in April 2023 while subject to a Community Treatment Or…

psychiatrygeneral medicinecommunicationsystemolanzapine
VIChome2026-07-30

Finding into death of PSD

66y · Female·Acute oesophagitis complicated by gastrointestinal haemorrhage

A 66-year-old woman with cerebral palsy, dysphagia, and chronic reflux oesophagitis presented with acute gastrointestinal bleeding while in supported disability accommodation. She was treated conservatively with IV proto…

emergency medicinegastroenterology
TAS2026-07-23

Coroner's Finding: Geard, Maurice

82y · Male·hypostatic pneumonia following recovery from left hip hemiarthroplasty due to fr…

Maurice Geard, an 82-year-old prisoner serving a 12-year sentence for sexual assault convictions, died on 19 March 2026 at Risdon Prison from hypostatic pneumonia following hip surgery. On 6 March 2026, he fell from a ch…

correctional healthgeriatric medicine
VICcommunity2026-07-23

Finding into death of Danielle Meredith Noonan

51y · Female·Chest sepsis in the setting of recurrent aspiration pneumonia, cerebral palsy, L…

Danielle Noonan, aged 51, died from chest sepsis secondary to recurrent aspiration pneumonia. She had severe disability including cerebral palsy, Lennox-Gastaut syndrome, spastic quadriplegia, and intellectual disability…

general medicineneurologymedicationcarbamazepine
VIChospital2026-07-23

Finding into death of Vicki Karon Grigg

67y · Female·Pulmonary thrombo-embolism secondary to deep venous thrombosis, with contributin…

Vicki Grigg, 67, died from pulmonary embolism three days after discharge from Goulburn Valley Health. She had been admitted with influenza A exacerbating asthma and COPD, and received standard-dose anticoagulation prophy…

respiratory medicineemergency medicinemedicationcommunicationenoxaparin
VICcommunity2026-07-15

Finding into death of Christopher Mark Tognon

42y · Male·Aspiration pneumonia complicating pancreatitis

Christopher Mark Tognon was a 42-year-old man with severe neurological disabilities including intellectual disability, cerebral palsy, spastic quadriplegia, blindness, and epilepsy. He was a resident in a specialist disa…

general medicine
VICcommunity2026-07-15

Finding into death of Guy Edwin Gellibrand

64y · Male·Complications of Severe Cerebral Palsy (Palliated)

Guy Edwin Gellibrand, 64, lived in supported NDIS accommodation with severe cerebral palsy, quadriplegia and non-verbal communication. In late September 2025, he presented to Monash Medical Centre with acute illness pres…

general practicegeneral medicine
VIChome2026-07-14

Finding into death of Philip Charles Arnott

70y · Male·Multiple organ failure secondary to bronchopneumonia and acute pancreatitis in a…

Philip Arnott, a 70-year-old man with schizophrenia, died from multiple organ failure secondary to bronchopneumonia and acute pancreatitis. He had taken the maximum recommended dose of paliperidone since 2015. Between Ja…

general medicinepsychiatrymedicationdiagnosticpaliperidone
NSWhospital2026-07-13

Inquest into the death of Wen Liang Zhang

57y · Male·Metastatic lung adenocarcinoma

Wen Liang Zhang was a 57-year-old remand prisoner diagnosed with metastatic lung adenocarcinoma shortly after arrest on 26 September 2025. He declined chemotherapy and radiotherapy, choosing palliative pain management in…

oncologypalliative careoxycodone
QLDhospital2026-07-08

Inquest into the death of Phillip Graeme Abell

51y · Male·Complications of stage 4 hepatocellular carcinoma

Phillip Graeme Abell, aged 51, died from stage 4 hepatocellular carcinoma (HCC) with underlying cirrhosis and hepatitis C infection. Imprisoned at Woodford Correctional Centre, Mr Abell was diagnosed with infiltrative HC…

hepatologygastroenterologycommunicationoxycodone
QLD2026-07-08

Inquest into the death of Francis Lex Deemal

70y · Male·Chronic kidney disease, with atherosclerotic cardiovascular disease and type 2 d…

Francis Lex Deemal, a 70-year-old Indigenous man from Hope Vale, Cape York, died at Mareeba Hospital on 2 August 2023 from chronic kidney disease, with atherosclerotic cardiovascular disease and type 2 diabetes as contri…

correctional healthnephrologyinsulin
QLDhospital2026-07-07

Inquest into the death of Maxwell John Beever

83y · Male·Metastatic melanoma

Maxwell John Beever, aged 83, died from metastatic melanoma on 8 July 2022 while in custody at Robina Hospital. A suspicious skin lesion was documented on 26 February 2021 but not investigated until 26 June 2021, delayin…

emergency medicinegeneral medicinedelaydiagnosticoxycodone
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
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