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NSW2025-09-15

Inquest into the death of Robert Sievers

81y · Male·COVID-19 infection on a background of Type 2 Diabetes and end stage chronic kidn…

Robert Sievers, an 81-year-old man incarcerated since 2001, died from COVID-19 infection on a background of type 2 diabetes and end-stage chronic kidney disease. Despite multiple warnings about vaccination, Sievers refus…

geriatric medicinepalliative careantiviral medication
NSWhospital2024-09-19

Inquest into the death of Denis Ives

78y · Male·COVID-19 pneumonitis on a background of ANCA nephropathy, hypertension, and diab…

Denis Ives, a 78-year-old man with type 1 diabetes, chronic kidney disease stage 4, ANCA nephropathy and hypertension, died of COVID-19 pneumonitis while in custody at Long Bay Correctional Centre. He tested positive for…

emergency medicineinfectious diseases
NSWhospital2023-08-11

Inquest into the death of Andrew Stubbs

32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome

Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…

general practicepsychiatrydiagnosticmedicationlithium
NSWcommunity2023-08-01

Inquest into the death of Peter Gretton

64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…

Peter Gretton, a 64-year-old man imprisoned at Junee Correctional Centre, died from metformin toxicity complicated by acute renal impairment and severe lactic acidosis. His renal function deteriorated in the three to fou…

emergency medicinecardiologydiagnosticcommunicationmetformin
NSWhospital2023-03-15

Inquest into the death of Matthew Smith

47y · Male·Follicular lymphoma with transformation to acute lymphoblastic leukaemia and the…

Matthew Geoffrey Smith, a 47-year-old man imprisoned for sexual offences, died in the ICU of Prince of Wales Hospital on 5 May 2022 from follicular lymphoma that had transformed to acute lymphoblastic leukaemia with comp…

oncologyhaematology
NSWhospital2022-08-17

Inquest into the death of Robert Bischard

75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…

Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…

orthopaedic surgerycardiologydiagnosticsystemfurosemide
NSW2021-11-30

Inquest into the death of Elias MELHEM

49y · Male·atherosclerotic and hypertensive cardiovascular disease, with type 2 diabetes me…

Elias Melhem, aged 49, died in custody from atherosclerotic and hypertensive cardiovascular disease with contributing type 2 diabetes. On 8 December 2019, he experienced chest pain at work but reported feeling better aft…

cardiologynephrologycommunicationinsulin
NSW2021-11-18

Inquest into the death of Conway PERRIE

75y · Male·Complications of chronic renal disease on a background of hypertension and type …

Conway Perrie, a 75-year-old man in lawful custody at Long Bay Correctional Complex, died from complications of chronic renal disease (stage 4) with hypertension and type 2 diabetes mellitus. He had been reviewed at Prin…

nephrologyemergency medicine
NSWhospital2021-10-05

Inquest into the death of Timothy MOFFATT

72y · Male·metastatic prostate carcinoma

Timothy Moffatt, a 72-year-old man in prison custody, died from metastatic prostate cancer. He had declined cancer treatment from 2014-2018 but agreed to chemotherapy after metastatic disease was identified. He also had …

oncologynephrologychemotherapy
NSWaged care2021-06-23

Inquest into the death of David Grahame Jones

88y · Male·General frailty and inanition; antecedent conditions: chronic cardiac and renal …

David Grahame Jones, aged 88, died in custody at Kevin Waller Aged Care Unit, Long Bay Correctional Centre from general frailty and inanition due to chronic cardiac and renal failure and diabetes. The coroner found he re…

geriatric medicinepalliative care
NSWhospital2021-05-25

Inquest into the death of Melvin LYNCH

72y · Male·Complications of subtotal colectomy for diffuse polyposis and invasive adenocarc…

Melvin Lynch, aged 72, died in custody at Prince of Wales Hospital on 9 December 2019, nine days after elective subtotal colectomy for bowel cancer. Post-operatively, he developed complications including pleural effusion…

colorectal surgerygeneral surgery
NSWhospital2020-02-12

Inquest into the death of Francis Sawle

82y · Male·Acute myocardial infarction caused by ischaemic heart disease

Francis Sawle, an 82-year-old man in custody, died of acute myocardial infarction due to ischaemic heart disease while an inpatient at Prince of Wales Hospital. He had significant comorbidities including severe triple ve…

cardiologypalliative careperindopril
NSW2018-11-15

Inquest into the death of Kenneth Johnstone

79y · Male·Complications associated with metastatic colorectal carcinoma and diabetes melli…

Kenneth Johnstone, a 79-year-old prisoner with extensive comorbidities including metastatic colorectal cancer, diabetes, stage 4 chronic kidney disease, and osteomyelitis, died from cancer complications. He was appropria…

oncologypalliative caremorphine
NSWhospital2018-10-10

Inquest into the death of Craig Catley

32y · Male·sudden cardiac arrhythmia

Craig Catley, aged 32, died of sudden cardiac arrhythmia while in prison custody one day after discharge from Prince of Wales Hospital following neurosurgery for a pituitary tumour. The coroner found his hospital care wa…

neurosurgeryintensive careclonidine
NSWhospital2018-10-10

Inquest into the death of Ian Turnbull

82y · Male·Acute kidney failure due to possible sepsis or cardiogenic shock, with congestiv…

Ian Turnbull, a 82-year-old man in custody, died from acute kidney failure due to possible sepsis or cardiogenic shock with congestive cardiac failure. He had multiple comorbidities including ischaemic heart disease, hyp…

cardiologyneurology
NSW2018-03-22

Inquest into the death of Clifford Deas

64y · Male·Arteriosclerotic coronary artery and hypertensive heart disease

Clifford Deas, a 64-year-old man in custody at Long Bay Hospital Correctional Centre since December 2015, died on 5 March 2016 from arteriosclerotic coronary artery disease and hypertensive heart disease, with end-stage …

cardiologynephrologycommunicationsystem
NSWhospital2017-07-06

Inquest into the death of Kerry Forrest

56y · Female·Complications of cervical cancer

Kerry Forrest, aged 56, died in custody on 26 January 2016 from complications of advanced cervical cancer. She was serving a 25-year sentence after being diagnosed with terminal cervical cancer in 2012, prior to sentenci…

palliative careoncology
NSWhospital2014-11-19

Inquests into the death of Luke WOOD

35y · Male·intraperitoneal haemorrhage from an anastomotic leak from a transplanted renal a…

Luke Wood, a 35-year-old kidney transplant recipient, died 11 days post-transplant from intraperitoneal haemorrhage due to anastomotic leak from the transplanted renal artery. While post-operative inpatient care and init…

transplant medicinenephrologycommunicationsystemlymphocyte immune globulin, anti-thymocyte globulin
NSWhospital2014-09-11

Inquest into the death of Stanley LORD

39y · Male·dilated cardiomyopathy

Stanley Allan Lord, a 39-year-old man, died from dilated cardiomyopathy while in custody at Prince of Wales Hospital. He had a long-standing cardiac history including prior myocardial infarction, presenting acutely with …

cardiologyintensive care

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