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QLD2026-05-26

Inquest into the death of Desmond George Buckby

74y · Male·Left cerebral ischaemic stroke caused by cerebral arterial cardioembolism

Desmond George Buckby, a 74-year-old prisoner detained under the Dangerous Prisoners (Sexual Offenders) Act, suffered a massive left cerebral ischaemic stroke caused by cardioembolism while in Wolston Correctional Centre…

emergency medicineneurologyalteplase
QLDhospital2026-03-06

Non-inquest findings into the death of Ms B

35y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to vertebro…

A 35-year-old woman presented to a rural hospital with a three-day history of collapses, slurred speech, vomiting, and abnormal eye movements. A non-contrast CT head scan was normal, and she was discharged with a diagnos…

emergency medicinegeneral practicediagnosticcommunication
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
QLDhospital2025-07-15

Inquest into the death of Errol George Radan

83y · Male·left middle cerebral artery cerebrovascular accident

An 83-year-old male prisoner died from a left middle cerebral artery stroke on 26 October 2022, seven days after presenting with acute stroke symptoms. Mr Radan had atrial fibrillation and was prescribed dabigatran for a…

neurologyemergency medicinedabigatran
QLDhospital2024-10-18

Findings into the death of John Ainsworth

68y · Male·Cerebrovascular disease

John Raymond Ainsworth, a 68-year-old prisoner, died of cerebrovascular disease following a severe stroke on 25 November 2020. He had poorly controlled Type II diabetes, hypertension, and high cholesterol. Prior to his a…

neurologyemergency medicinedelaymetformin
QLD2024-06-18

Inquest into the deaths of Shiralee Deanne Tilberoo and Vlasta Wylucki

Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…

Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…

cardiologyaddiction medicineproceduralcommunicationdiazepam
QLDhospital2024-04-22

Non-inquest findings into the death of Lenore

48y · Female·Hypoxic ischaemic encephalopathy due to pulmonary thromboembolism due to deep ve…

A 48-year-old woman with morbid obesity and smoking history presented to a rural hospital with severe hip and leg pain. Over five days across two hospitals, no venous thromboembolism (VTE) risk assessment was performed d…

emergency medicineorthopaedic surgerydiagnosticsystemoxycodone
QLDhospital2024-03-07

KLUMPER Joshua William

17y · Male·Hanging

17-year-old Joshua Klumper died by hanging following cannabis withdrawal and workplace stress. He had a complex mental health history with ASD diagnosis (lacking robust diagnostic support), multiple suicide attempts, and…

psychiatryemergency medicinecommunicationsystemcannabis
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
QLDhospital2023-01-24

Smith, David Frederick

45y · Male·Haemorrhagic transformation of cerebral infarction, due to bilateral internal ca…

David Smith, aged 45, died from haemorrhagic transformation of cerebral infarction secondary to essential thrombocytosis with bilateral internal carotid artery thrombosis. He developed an acute ischaemic stroke on 9 July…

haematologyneurologysystemrivaroxaban
QLD2022-09-02

Mitchell, Vanelee Curtis

30y · Male·Sudden unexpected death in epilepsy

Vanelee Mitchell, a 30-year-old First Nations man with epilepsy, died suddenly in custody at Townsville Correctional Centre on 10 April 2020. He had suffered a head injury in 2014 resulting in acquired brain injury and s…

neurologycorrectional healthsystemsodium valproate
QLDhome2022-06-30

Tabuai, James Daniel

0y · Male·Acute traumatic head injury (non-accidental)

A 7-month-old child died from acute traumatic head injury sustained from non-accidental blunt force. Clinical lessons include: medical staff should strongly reinforce urgent referrals (the child had a critical GP referra…

general practiceemergency medicinecommunicationdelay
QLD2021-11-30

Williams, Craig Leeton

45y · Male·Recurrence of ventricular fibrillation due to Brugada Syndrome

Craig Williams, 45, suffered an out-of-hospital cardiac arrest in 2015 due to presumptive Brugada Syndrome. He survived with severe hypoxic brain injury and spent 10 months rehabilitating at Cairns Hospital, where he was…

cardiologyrehabilitation medicinecommunicationsystemamitriptyline
QLDcommunity2021-09-10

Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings

49y · Female and male·Gunshot wound to head inflicted by spouse

Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…

general practicepsychiatrydiagnosticcommunicationcannabis
QLD2021-08-20

Caramin, Olivier Max - Non-inquest findings

27y · Male·multiple organ failure due to or as a consequence of heat stroke

Olivier Caramin, a 27-year-old Belgian national on a working holiday visa, died from heat stroke while picking pumpkins on 31 October 2017 in Far North Queensland. He was just three days into farm work without proper acc…

occupational and environmental healthemergency medicinesystemdiagnostic
QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

Teresa Bradford, aged 40, was killed by her husband David Bradford in a premeditated domestic homicide at their Pimpama home on 31 January 2017, followed by his suicide. She died from head injuries inflicted with an axe.…

general practicepsychiatrycommunicationsystemwarfarin
QLD2021-05-04

Hambly, Scott

38y · Male·Aspiration pneumonia

Scott Hambly, a 38-year-old life prisoner with dilated cardiomyopathy, epilepsy, and schizophrenia, died from aspiration pneumonia at Wolston Correctional Centre in December 2018. He was identified as needing cardiology …

cardiologypsychiatrycommunicationsystembisoprolol
QLDcommunityPodcast2020-06-26

Nyholt, Nicole Sonia and Clark, Margaret Louisa

Female·Burns due to gas explosion due to motor vehicle collision with building

A 60-year-old man with a long-standing history of seizures experienced an epileptic seizure while driving and lost control of his vehicle. It collided with an LPG gas cylinder outside a café, triggering an explosion that…

emergency medicineneurologycommunicationsystem
QLDhome2019-11-06

Follent, Mitchell James - Non-inquest findings

22y · Male·Multiple injuries from fall from height

Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired b…

psychiatryneurologydiagnosticcommunicationolanzapine
QLDPodcast2019-08-30

Pike, Kerri Anne; Dawson, Peter Michael and Turner, Tobias John

Unknown·multiple physical injuries sustained in a mid-air collision during skydiving

Three skydivers died in a mid-air collision near Mission Beach, Queensland on 13 October 2017. Tandem instructor Peter Dawson and customer Kerri Pike (in drogue-fall) collided with solo sport jumper Tobias Turner whose m…

aviation medicineneurologysystemdelaynordiazepam

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