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QLDhospital2026-05-07

Non-inquest findings into the death of Lucy Campbell

0y · Female·Severe hypoxic ischaemic encephalopathy, result of brain injury as a consequence…

Lucy Campbell, a neonate born on 16 February 2024, died from severe hypoxic ischaemic encephalopathy following a complicated assisted vaginal birth at a rural level 3 hospital. The mother underwent induction of labour at…

obstetricsobstetricsdiagnosticcommunicationoxytocin
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
VIChospital2026-05-04

Finding into death of Baby E

3y · Female·COMPLICATIONS FROM SEVERE CEREBRAL PALSY

Baby E, a 3-year-old with severe cerebral palsy, spastic quadriplegia, bulbar dysfunction and upper airway obstruction, died from complications of her severe cerebral palsy. She presented with seizures, dark green sputum…

intensive carepaediatrics
WA2026-04-28

Inquest into the Death of Corey Desmond DEVREE

41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…

Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…

psychiatrygeneral practicediagnosticcommunication
VIChospital2026-04-28

Finding into death of Ronald William Beaumont

74y · Male·Acute myocardial infarction complicated by multiple organ failure

Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…

cardiologyorthopaedic surgerymedicationcommunicationaspirin
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
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
VIChospital2026-04-17

Finding into death of White-Wolf Patricia Mclellan

44y · Female·Pulmonary thromboembolism complicating a fractured left ankle (not operated), su…

A 44-year-old woman died from pulmonary thromboembolism 27 days after sustaining a Weber B ankle fracture from a fall. She was managed conservatively with a CAM boot then below-knee cast, with progressive immobilisation …

emergency medicineorthopaedic surgerysystemcommunicationtenecteplase
WAhospital2026-04-01

Inquest into the Death of David John HATCHER

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

A 60-year-old man remanded in custody died from pulmonary tuberculosis complicated by severe COPD. Key clinical issues included: delayed diagnosis (TB not suspected at intake despite respiratory symptoms), patient's refu…

respiratory medicineinfectious diseasessystemdelaytb treatment
QLDhospital2026-03-31

Inquest into the death of Robyn Ann Beale

78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …

A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…

general surgeryanaesthesiadiagnosticcommunicationoxycodone
QLD2026-03-31

Inquest into the death of Kyle James Gallagher

22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…

Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…

ENT surgeryradiologydiagnosticcommunicationdiazepam
TAS2026-03-23

Coroner's Finding: Garcia, Adrian Walter

51y · Male·Traumatic brain injuries resulting from blunt head trauma: multiple calvarial an…

Adrian Garcia, 51, died from traumatic brain injuries sustained during an assault in a public park in Sorell, Tasmania on 10 March 2021. He was heavily intoxicated when struck by a baseball bat multiple times by his fian…

neurosurgeryintensive care
NSWhospital2026-03-19

Inquest into the death of Eve Brown

42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…

Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…

emergency medicinegeneral practicediagnosticcommunicationceftriaxone
VIChospital2026-03-13

Finding into death of Wayne Ronald Watson

61y · Male·Intracranial haemorrhage and myocardial infarct

A 61-year-old man with extensive cardiac disease collapsed at a supermarket, striking his head and losing consciousness for less than 10 seconds. Paramedics identified STEMI and administered heparin on advice from Austin…

cardiologyemergency medicinediagnosticcommunicationheparin
VIChospital2026-03-12

Finding into death of Nicole Jennifer Kateiva

39y · Female·Respiratory failure in the setting of aspiration pneumonia in a woman with arthr…

Nicole Kateiva, a 39-year-old woman with arthrogryposis multiplex congenita, intellectual impairment, and epilepsy, died from respiratory failure due to aspiration pneumonia. She presented to hospital with two days of co…

general medicineintensive careceftriaxone
NSW2026-03-12

Inquest into the death of Evander Tuala

23y · Male·Blunt force head injury

A 23-year-old man died from blunt force head injury after being struck during a violent altercation outside a Sydney hotel. He fell backwards, striking the back of his head on concrete and suffered multiple intracranial …

emergency medicineneurosurgery
VICcommunity2026-03-04

Finding into death of Anthony Laurence Parisi

39y · Male·Multidrug toxicity (GHB, methylamphetamine, ketamine) in a setting of restraint …

Anthony Parisi, 39, died from multidrug toxicity (GHB, methamphetamine, ketamine) in a setting of police restraint and moderate coronary artery atherosclerosis. He consumed large quantities of GHB and methamphetamine on …

emergency medicineintensive caregamma-hydroxybutyrate
VIChome2026-03-04

Finding into death of Carol Fay Slade

54y · Female·Severe burns sustained in a house fire (palliated)

Carol Fay Slade, a 54-year-old woman with acquired brain injury from a 2003 motorcycle accident and mobility limitations, died from severe burns sustained in a house fire at her public housing property in Shepparton. The…

emergency medicineintensive caresystemmethadone
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