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VICcommunityNew2026-07-03

Finding into death of Con Panagiotou

76y · Male·Traumatic head, ribs, pelvic and spinal injuries sustained in a motor vehicle in…

A 76-year-old man with schizophrenia, depression, Klinefelter syndrome, and poorly controlled diabetes was struck by a car as a pedestrian on 19 December 2024 while crossing Middleborough Road in Box Hill South outside a…

emergency medicineintensive care
QLDhospitalNew2026-07-02

Inquest into the death of Jeffrey Stewart Olsen

64y · Male·Colonic adenocarcinoma and its treatment

Jeffrey Olsen, 64, died from acute capecitabine toxicity during adjuvant chemotherapy for Stage 3b colorectal cancer. Within three days of commencing treatment in September 2020, severe side effects including diarrhea, r…

oncologygeneral surgerycapecitabine
VIChospitalNew2026-07-01

Finding into death of HJW

69y · Female·Urosepsis secondary to anuric acute renal failure and corona radiata infarct; co…

A 69-year-old diabetic woman presented to Maroondah Hospital Emergency Department on 9 June 2024 with severe right-sided abdominal pain and vomiting. CT imaging at 10:00am confirmed emphysematous pyelitis (gas-forming ki…

emergency medicinegeneral medicinediagnosticdelayfentanyl
VIChomeNew2026-06-29

Finding into death of Pamela Dorothy Otway

71y · Female·Cardiogenic shock due to sudden cardiac event, with scleroderma as contributing …

Pamela Dorothy Otway, aged 71 years, with significant intellectual disability from childhood and residing in Specialist Disability Accommodation, died of cardiogenic shock and ventricular standstill following a sudden ca…

emergency medicineintensive care
QLDcommunityNew2026-06-26

Inquest into the death of Wayne Thomas Kerle

68y · Male·Cardiac arrest - unascertained etiology with multiple contributing factors inclu…

Wayne Thomas Kerle, 68, was arrested at his home for cannabis possession. Queensland Ambulance Service paramedics assessed him when he reported respiratory distress but cleared him for police custody after a limited exam…

paramedicineemergency medicinediagnosticproceduraldiazepam
VIChospitalNew2026-06-25

Finding into death of Lynn Maree Sturgess

65y · Female·Bronchopneumonia and rhinovirus infection in a woman with cerebral palsy and epi…

Lynn Maree Sturgess, aged 65, a long-term resident of supported disability accommodation with cerebral palsy and well-controlled epilepsy, was admitted to Bendigo Hospital with febrile illness in May 2025. She was diagno…

general medicineintensive care
VIChomeNew2026-06-19

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
NSWhospitalNew2026-06-19

Inquest into the Death of Simon Myles Mackay

37y · Male·Neck compression and the complications thereof

Simon Mackay, age 37, was admitted as an involuntary psychiatric patient on 12 July 2022 for acute methamphetamine-induced psychosis with paranoia and aggression, complicated by severe polysubstance dependence. Although …

psychiatryaddiction medicinepaliperidone
VIChomeNew2026-06-15

Finding into death of Darren Russell Collyer

48y · Male·Complications of an intra-cranial haemorrhage

Darren Collyer, a 48-year-old man with Sotos syndrome, intellectual disability, epilepsy and anxiety, lived in specialist disability accommodation (SDA) in Melton. On 14 December 2023, a new unfamiliar staff member trigg…

disability medicineemergency medicinesertraline
VIChospital2026-06-12

Finding into death of Helen Mahlis

87y · Female·Oesophageal perforation following an elective oesophageal dilatation, secondary …

87-year-old Helen Mahlis died from oesophageal perforation following an elective balloon dilation procedure at Epworth Richmond for treatment of achalasia. The coroner identified two contributing factors: use of a 35mm b…

gastroenterologygeneral surgeryproceduraldiagnostic
NSWNew2026-06-11

Inquest into the death of Dictor Dongrin

29y · Male·Cardiac arrhythmia in the context of alcohol withdrawal and chronic alcohol misu…

A 29-year-old man died from cardiac arrhythmia in the context of severe alcohol withdrawal at a correctional facility. Initial assessment correctly identified moderate-to-severe withdrawal (AWS score 8) with seizure hist…

addiction medicinecorrectional healthdiagnosticmedicationalcohol
VIChomeNew2026-06-03

Finding into death of FBN

55y · Male·Unascertained

A 55-year-old man with known HIV infection, who was homeless and vulnerable, was found unconscious in a hot bath at a friend's home in South Yarra and rapidly transported to hospital. He presented with profound shock, hy…

emergency medicineintensive caremethamphetamine
NSWhospital2026-06-01

Inquest into the death of Michael Anthony Guider

73y · Male·Thromboembolism on a background of a spindle cell tumour

Michael Anthony Guider, aged 73, was an inmate in NSW correctional custody when he developed progressive shortness of breath and lower limb swelling. He presented to Prince of Wales Hospital on 6 September 2024 and was f…

cardiologycorrectional health
VIChome2026-05-29

Finding into death of Baby R

0y · Male·Perinatal hypoxia

Baby R, born at 39 weeks 6 days via planned homebirth with private midwives, died from perinatal hypoxia on day 6 of life. The mother had significant obstetric risk factors: previous emergency caesarean section, macrosom…

obstetricsmidwiferydiagnosticcommunication
VIChospital2026-05-22

Finding into death of Stratos Ioannidis

45y · Male·focal coronary artery disease and cardiomegaly

Stratos Ioannidis, age 45, died at Maroondah Hospital on 28 March 2025 from focal coronary artery disease and cardiomegaly during an involuntary psychiatric admission. He presented with acute psychosis from bipolar disor…

psychiatryemergency medicinecommunicationsystemolanzapine
ACThospital2026-05-12

Inquest into the death of Mr Deleman

69y · Male·peritonitis due to perforated bowel

Mr Deleman was a 69-year-old man with untreated schizophrenia, advanced liver cirrhosis, and hepatitis C, presenting to hospital on 1 April 2024 with abdominal swelling. He was admitted to The Canberra Hospital and place…

emergency medicinegastroenterologypaliperidone
QLDhospital2026-05-07

Non-inquest findings into the death of Lucy Campbell

0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…

Lucy Margaret Campbell died eight days after birth from severe hypoxic ischemic encephalopathy following complicated assisted vaginal birth at Ingham Hospital. Her mother had a low-risk pregnancy complicated by spontaneo…

obstetricsmidwiferydiagnosticcommunicationoxytocin
VICcommunity2026-05-07

Finding into death of Elizabeth Susan Edwina Ferris

44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…

Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…

psychiatryintensive carediagnosticcommunicationheroin
VICaged care2026-05-06

Finding into death of Cornelia Groot

87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…

An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…

geriatric medicineemergency medicinediagnosticcommunicationoxycodone
NSWchildcare2026-05-06

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
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