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VICNew2026-08-27

Finding into death of Allan James Anton

64y · Male·Complications of Alzheimer's dementia

Allan Anton, aged 64, died on 24 September 2025 from complications of Alzheimer's dementia at his specialist disability accommodation in Tarneit. He was diagnosed with younger onset dementia in November 2021 following a …

general practiceoccupational therapy
VIChomeNew2026-08-25

Finding into death of BP

33y · Female·Combined drug toxicity (heroin, benzodiazepines, methylamphetamine, mirtazapine,…

BP, a 33-year-old female with longstanding opioid and polysubstance use disorder, died from accidental heroin overdose at home with concomitant CNS depressants (benzodiazepines, mirtazapine, promethazine) and stimulant (…

emergency medicineaddiction medicineheroin
VIChospitalNew2026-08-21

Finding into death of Susanne Keating

64y · Female·Presumed massive pulmonary embolus

Mrs Keating, aged 64, presented to University Hospital Geelong ED with a two-day history of shortness of breath and cough, with known history of pulmonary embolism. Attending physicians appropriately considered PE as dif…

emergency medicinegeneral practicedelaysystem
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
SAaged careNew2026-08-21

Coroner's Finding: Clark, Wayne Malcolm

84y · Male·bronchopneumonia complicating C2 odontoid fracture (palliated) due to fall on a …

Wayne Malcolm Clark, aged 84, with advanced Alzheimer's and vascular dementia, fell in a secure residential aged care facility and sustained a C2 odontoid fracture. He died on 23 August 2023 from bronchopneumonia complic…

general practiceparamedicineparacetamol
VIChomeNew2026-08-20

Finding into death of Dorothy Boag

91y · Female·Aspiration pneumonia in a woman with multiple co-morbidities

91-year-old woman with disability living in specialist disability accommodation who died from aspiration pneumonia. She had documented moderate oropharyngeal dysphagia from prior stroke, managed with pureed diet and thic…

general practicegeriatric medicine
SAhospitalNew2026-08-19

Coroner's Finding: Mohammadi, Sohaila

47y · Female·head injury

Sohaila Mohammadi (47) was killed in a motor vehicle collision caused by driver Tristan Mourant, who had bilateral retinal dystrophy and was advised by three medical professionals not to drive. However, none of the docto…

ophthalmologygeneral practiceproceduralsystemalcohol
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
WAcommunityNew2026-08-07

Inquest into the Death of Bradley Craig BUSWELL

41y · Male·combined drug toxicity

Bradley Craig Buswell, 41, died from combined drug toxicity (olanzapine, mirtazapine, doxylamine) on 31 March 2025 at his home in Eaton. He had treatment-resistant schizophrenia with chronic psychotic symptoms including …

psychiatrygeneral practiceolanzapine
NSW2026-08-07

Inquest into the death of Amanawel Ayai

23y · Male·complications of bowel obstruction by adhesions

A 23-year-old man in lawful custody at Parklea Correctional Centre presented on 7 January 2022 with severe chest pain, abdominal pain, vomiting, and dehydration, with a significant history of previous abdominal surgery a…

correctional healthgeneral practicediagnosticcommunicationmetoclopramide
VIChomeNew2026-08-06

Finding into death of Margaret Mary Broderick

62y · Female·Complications of WHO Class III obesity in a woman with epilepsy

Margaret Mary Broderick, 62, with intellectual disability, autism, schizophrenia (managed on clozapine), epilepsy, and severe obesity (BMI 48.2), lived in specialist disability accommodation provided by Scope Australia i…

general practicepsychiatry
SAhospital2026-08-06

Coroner's Finding: Burg, Claus Hartmuth

70y · Male·metastatic gastric adenocarcinoma

A 70-year-old man with prior bladder cancer was undergoing routine CT surveillance. Stomach cancer signs were clearly visible on February 2017 and February 2018 CT scans but failed to be detected by consulting radiologis…

radiologyoncologydiagnosticcommunication
VICcommunityNew2026-08-04

Finding into death of Wayne Thomas Pistrucci

56y · Male·End stage renal failure in a man with cerebral palsy

Wayne Thomas Pistrucci, a 56-year-old man with cerebral palsy, intellectual disability, end-stage renal failure, and liver disease, died from end-stage renal failure on 9 December 2024. He was living in Specialist Disabi…

general practicepalliative care
VICaged care2026-07-29

Finding into death of Rosemary Elsie Harriet Jacoby

94y · Female·Drug toxicity (baclofen, gabapentin, oxycodone, pregabalin, zolpidem)

A 94-year-old residential aged-care resident died from drug toxicity after receiving another resident's medications. An agency nurse, unfamiliar with the patient and interrupted during medication preparation, failed to p…

general practiceemergency medicinemedicationcommunicationbaclofen
VICaged care2026-07-29

Finding into death of Lynette Patricia McHarry

69y · Female·Exacerbation of chronic obstructive pulmonary disease and ischaemic heart diseas…

Lynette McHarry, aged 69, died on 15 August 2024 at Casey Hospital following complications from a preventable medication error at Mooraleigh Hostel residential aged care facility. On 4 August, she was mistakenly administ…

geriatric medicinegeneral practicemedicationsystemclozapine
VICaged care2026-07-29

Finding into death of Mrs LV

78y · Female·medication error resulting in combined drug toxicity

Mrs LV, age 78, died at The Bays Aged Care facility on 2 January 2025 following a medication error four days earlier. An endorsed enrolled nurse (EEN), distracted by a phone call during her first shift, inadvertently adm…

general practicemedicationsystempregabalin
VIChome2026-07-24

Finding into death of Wayne Douglas Scott

51y · Male·High blood alcohol and positional asphyxia in a man with cerebral palsy and acqu…

Wayne Douglas Scott, 51, died from high blood alcohol and positional asphyxia at his home in Lalor, Victoria. He had cerebral palsy, low vision, dysarthria, depression, and acquired brain injury from a drug overdose more…

general practicepsychiatryalcohol
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
VIChome2026-07-23

Finding into death of Adam Donald Baker

50y · Male·Cerebral haemorrhage (cause unknown)

Adam Donald Baker, a 50-year-old man with Christianson Syndrome (a genetic disorder causing intellectual disability and seizures), died from cerebral haemorrhage of unknown cause while residing in supported disability ac…

general practiceneurologylevetiracetam

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