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VICmental health2026-04-27

Finding into death of GM

Female·Fulminant hepatic failure due to paracetamol toxicity

A 19-year-old female with anorexia nervosa, borderline personality disorder, and chronic suicidality was admitted to St Vincent’s psychiatric inpatient unit on 28 July 2023. She reported ongoing suicidal thoughts but eng…

psychiatryintensive careparacetamol
WAhospital2026-03-09

Inquest into the Death of Russell Graham PENNY

56y · Male·complications of viral hepatitis related advanced-chronic liver disease (medical…

Russell Graham Penny, a 56-year-old Aboriginal man, died from complications of advanced chronic liver disease with hepatocellular carcinoma while imprisoned at Casuarina Prison. He had a long history of hepatitis C and c…

gastroenterologyhepatologycommunicationsystem
VIChospital2026-02-10

Finding into death of David James Dorling

59y · Male·multiorgan failure complicating paracetamol toxicity

David James Dorling, a 59-year-old man with multiple sclerosis, ischaemic heart disease, and diabetes, ingested 90-100 paracetamol tablets on 1 February 2024 with suicidal intent. He attended court the next day and was r…

emergency medicineintensive careparacetamol
SAhospital2025-11-14

Coroner's Finding: Wallace, Peter John

67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …

Peter John Wallace, aged 67, died in custody at Lyell McEwin Hospital from hypoxic respiratory failure complicating pneumonia, pulmonary embolism, and advanced hepatocellular carcinoma. He had been imprisoned at Yatala L…

hepatologyoncologyenoxaparin
QLDhospital2025-10-08

Inquest into the death of Janis Ellen Doherty

57y · Female·Multi-organ failure due to drug-induced liver injury caused by sodium valproate …

Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nau…

neurologyhepatologydiagnosticmedicationsodium valproate
QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…

emergency medicineinfectious diseasesdiagnosticdelayantacid
VIChospital2025-08-19

Finding into death of Con Koumis

43y · Male·complications of decompensated liver failure due to occult sepsis and retroperit…

Con Koumis, a 43-year-old man with beta-thalassaemia major requiring regular blood transfusions, died from decompensated liver failure complicated by occult sepsis and retroperitoneal haemorrhage. He was remanded in cust…

haematologyhepatology
WAhospital2025-05-08

Inquest into the Death of Tony RUICH

55y · Male·decompensated liver failure in a man with metastatic hepatocellular carcinoma, w…

Tony Ruich, a 55-year-old sentenced prisoner, died from decompensated liver failure due to metastatic hepatocellular carcinoma with terminal palliative care. He had pre-existing cirrhosis diagnosed in 2012, likely from h…

hepatologypalliative careheroin
VIChome2025-02-11

Finding into death of Kathleen Dawn Arnold

30y · Female·Acute ethanol toxicity on a background of chronic alcoholism

Kathleen Arnold, aged 30, died from acute ethanol toxicity on a background of chronic alcoholism. She had a 20-year history of alcohol dependence, complex trauma from a childhood near-drowning incident, eating disorders,…

addiction medicinepsychiatrysystemalcohol
WAAugust 2024

Inquest into the Death of Robert Allan EXELL

55y · Male·Complications of liver cirrhosis and hepatocellular carcinoma in a man with mult…

Robert Exell, a 55-year-old Aboriginal man, died from complications of liver cirrhosis and hepatocellular carcinoma while in custody. He had chronic hepatitis C and alcohol-related liver disease since at least 2012. Key …

hepatologygastroenterologydelaysystemmorphine
QLDhospital2024-12-16

Inquest into the death of Shane Anthony May

61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…

Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory…

emergency medicinerespiratory medicineamlodipine
VIChospital2024-12-09

Finding into death of Debra Louise Goold

61y · Female·Decompensated liver failure - Child's Pugh B cirrhosis secondary to renal failur…

Debra Louise Goold, a 61-year-old NDIS participant living in Specialist Disability Accommodation, died from decompensated liver failure (Child's Pugh B cirrhosis) and renal failure. She was admitted to Ballarat Base Hosp…

hepatologygeneral medicine
VIChospital2024-10-28

Finding into death of Loreta Maria Del Rossi

98y · Female·Multi-organ failure following amanita poisoning

A 98-year-old woman died from multi-organ failure following amanita (death cap) mushroom poisoning. She had foraged wild mushrooms from her garden in April 2024 without incident, then consumed mushrooms from the same loc…

toxicologyemergency medicineactivated charcoal
WAhospital2024-04-04

Inquest into the Death of Karl Frederick Dominic HOLMES

66y · Male·Complications of metastatic lung adenocarcinoma, with terminal palliative care, …

Karl Frederick Dominic Holmes, a 66-year-old prisoner with metastatic lung adenocarcinoma and hepatocellular carcinoma, died from complications of his terminal cancer while serving a 7-year sentence. He received excellen…

oncologypalliative caresystemdelaymorphine
VIC2024-02-12

Finding into death of Maahi Tukapua

73y · Male·Acute on chronic renal failure and multi-factorial encephalopathy in a man with …

A 73-year-old man with significant comorbidities (cirrhosis, dilated cardiomyopathy, chronic kidney disease) died in prison from acute-on-chronic renal failure, hepatic encephalopathy, and multiorgan failure. He was init…

cardiologynephrologymorphine
WAhospital2024-01-12

Inquest into the Death of Herbert William MACKAY

45y · Male·complications associated with metastatic adenocarcinoma of the lung, treated pal…

Herbert Mackay, a 45-year-old Aboriginal man, died from complications of metastatic adenocarcinoma of the lung discovered at stage 4 in late December 2020 while imprisoned at Casuarina Prison. He presented with respirato…

oncologycardiothoracic surgery
SA2023-12-22

Coroner's Finding: Schuster, Gavin Shawn

45y · Male·Liver failure due to metastatic hepatocellular carcinoma

A 45-year-old male prisoner died from liver failure due to metastatic hepatocellular carcinoma. He had been prescribed cyproterone (Androcur) for 20+ years as an anti-libidinal agent, with regular blood tests monitoring …

psychiatryoncologycyproterone
NSWhospital2023-09-12

Inquest into the death of Anthony Sampieri

57y · Male·hepatocellular carcinoma and its complications

Anthony Sampieri, 57-year-old inmate with end-stage hepatocellular carcinoma secondary to hepatitis C and cirrhosis, died at Prince of Wales Hospital Correctional Annex after 10 days of palliative care. He had received a…

oncologypalliative care
QLDhospital2023-08-17

Schwartz, Thomas Edward

64y · Male·End stage liver disease due to Hepatitis C and non-alcoholic fatty liver disease

Thomas Edward Schwartz, a 64-year-old prisoner, died from end-stage liver disease due to Hepatitis C and non-alcoholic fatty liver disease. He was transferred from Wolston Correctional Centre to Princess Alexandra Hospit…

gastroenterologyhepatologyoxazepam
VIChospital2023-08-14

Finding into death of Md Fakrul Alam Sozon

33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …

A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Phy…

gastroenterologyintensive careproceduraldiagnostic

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