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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
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
VIChome2026-07-06

Finding into death of Grant Douglas Griffiths

66y · Male·Complications arising from the combined features of HIV infection, multiple cere…

Grant Douglas Griffiths, a 66-year-old man with HIV, multiple cerebrovascular accidents, progressive dementia, and other comorbidities, deteriorated significantly after admission to hospital in March 2022 due to function…

infectious diseasesgeneral medicinemorphine
VIChome2026-06-19

Finding into death of Annette Kelly

74y · Female·Aspiration pneumonia

Annette Kelly, 74 years old, died from aspiration pneumonia at Wantirna Palliative Care after brief hospitalisation at Box Hill Hospital in October 2025. She was a long-term Specialist Disability Accommodation resident w…

general practiceinfectious diseases
VIChome2026-06-19

Finding into death of Elizabeth Jean Hanlon

38y · Female·Pulmonary thromboembolism secondary to deep venous thrombosis due to promethazin…

Elizabeth Jean Hanlon, aged 38, died from pulmonary thromboembolism secondary to deep venous thrombosis following a promethazine overdose. She had complex mental health diagnoses including borderline personality disorder…

psychiatryintensive carepromethazine
VICcommunity2026-05-22

Finding into death of Loretta Therese Ward

64y · Female·Urosepsis and pneumonia on a background of dementia and cognitive decline

Loretta Therese Ward, aged 64, was living in Specialist Disability Accommodation (SDA) under NDIS support due to Lewy Body dementia and cognitive decline when she developed progressive illness in late 2024. On 24 Februar…

palliative caregeneral medicine
NSW2026-05-06

Inquest into the death of Arianna Maragol

1y · Female·Rapidly developing Streptococcus pneumoniae infection leading to invasive pneumo…

Arianna Maragol, a 16-month-old girl, died from rapidly developing Streptococcus pneumoniae infection leading to invasive pneumococcal disease while in childcare on 24 August 2018. Key clinical lessons emerged: (1) Pneum…

paediatricsemergency medicinesystemcommunicationibuprofen
VICaged care2026-04-28

Finding into death of Graham Peter Moore

61y · Male·Pneumonia complicating Trisomy 21

Graham Peter Moore, a 61-year-old man with Down syndrome, epilepsy, and early-onset dementia living in residential care, died of pneumonia on 8 December 2025. He developed community-acquired pneumonia in late November, w…

respiratory medicineinfectious diseases
SAhospital2026-04-23

Coroner's Finding: Wilson, Charles Thomas

85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …

An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …

cardiologygeriatric medicinemedicationcommunicationmetoprolol
VIChospital2026-04-14

Finding into death of Giovanni John Miceli

53y · Male·Sepsis secondary to aspiration pneumonia

Giovanni John Miceli, a 53-year-old man with cerebral palsy and intellectual disability living in specialist disability accommodation, died from sepsis secondary to aspiration pneumonia. He had a known history of recurre…

infectious diseasesemergency medicineantibiotics
VICcommunity2026-04-13

Finding into death of Nikki Maree Francis

40y · Female·Complications of influenza A infection in a woman with Moebius syndrome (palliat…

A 40-year-old woman with Moebius syndrome, cerebral palsy and intellectual disability died from complications of influenza A infection. She resided in specialist disability accommodation with 24/7 support. On 3 July, she…

emergency medicineinfectious diseases
WAhospital2026-04-01

Inquest into the Death of David John HATCHER

60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…

David John Hatcher, aged 60, was a remand prisoner at Hakea who died at Fiona Stanley Hospital on 27 September 2024 from pulmonary tuberculosis superimposed on severe chronic obstructive pulmonary disease. He was hospita…

respiratory medicineinfectious diseasesproceduralsystem
SAhospital2026-02-26

Coroner's Finding: Lowery, Nahuel Sebastian

41y · Male·Acute liver failure with contributing Castleman's disease

A 41-year-old Aboriginal man with HIV and Castleman's disease died from acute liver failure while on home detention. He had variable compliance with antiretroviral therapy, exacerbated by amphetamine use disorder and men…

infectious diseasesintensive careantiretroviral therapy
VIChospital2026-02-23

Finding into death of Lani-Kay Roxanna Illsley

55y · Female·Combined effects of influenza A infection, acute kidney injury, and aspiration p…

Lani-Kay Illsley, a 55-year-old woman with Rett syndrome residing in specialist disability accommodation, died from combined effects of influenza A infection, acute kidney injury, and aspiration pneumonia. She was admitt…

emergency medicineinfectious diseases
VIChospital2026-02-23

Finding into death of William Thomas Kerby

80y · Male·Pneumonia in a man with multiple medical comorbidities

William Thomas Kerby, an 80-year-old man with intellectual disability, epilepsy, and bipolar disorder living in specialist disability accommodation, died from community-acquired pneumonia with pleural effusion and multi-…

emergency medicineinfectious diseases
VIChospital2026-02-20

Finding into death of Brian Robert Dean

44y · Male·Sepsis due to Streptococcus pyogenes (Group A Streptococcus) septicaemia complic…

Brian Dean, a 44-year-old with obesity, presented to hospital on 1 July 2023 with influenza A and signs of shock (tachycardia, hypotension, elevated lactate). He was treated with fluids and discharged the next morning ap…

emergency medicineinfectious diseasesdiagnosticdelayondansetron
VIChospital2026-02-16

Finding into death of Marcello Sardo

60y · Male·Aspiration pneumonitis in a man with Down Syndrome

Marcello Sardo, a 60-year-old man with Down syndrome and early-onset Alzheimer's dementia, died from aspiration pneumonitis at Austin Hospital. He had been receiving palliative care in the community following his geriatr…

geriatric medicinepalliative care
VIChospital2026-01-27

Finding into death of Michael Francis Gribble

58y · Male·Sepsis of unknown origin on a background of multiple co-morbidities

Michael Francis Gribble, a 58-year-old man with complex medical comorbidities including alcoholic cardiomyopathy, schizophrenia, and acquired brain injury, died from sepsis of unknown origin at Rosebud Hospital. He was f…

emergency medicineinfectious diseases
VIChospital2026-01-13

Finding into death of Sushant Padhye

56y · Male·Recurrent aspiration pneumonia in a man with congenital disability and cognitive…

A 56-year-old man with congenital microcephaly, intellectual disability, dysphagia and recurrent aspiration pneumonia died from aspiration pneumonia whilst receiving palliative care in hospital. He had multiple episodes …

emergency medicinepalliative carecarbamazepine
NSWhospital2026-01-13

Inquest into the death of Paul Harris

43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…

Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …

general practiceemergency medicinediagnosticcommunicationceftriaxone
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