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ACTcommunity2026-05-26

Inquest into the death of Donald Morley

93y · Male·Complications of invasive squamous cell carcinoma of the scalp

Donald Morley, aged 93, died at Claire Holland House hospice on 12 July 2024 while serving a nine-year sentence for murder. He was under 24/7 custodial supervision. The cause of death was complications of invasive squamo…

palliative carepsychiatry
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
VIChome2026-05-25

Finding into death of Robyn Julia Richards

69y · Female·Hydrocephalus and subarachnoid haemorrhage in the setting of a fall in a woman w…

A 69-year-old woman with cerebral palsy, intellectual disability, and B cell acute lymphoblastic leukaemia, residing in Specialist Disability Accommodation funded through the National Disability Insurance Scheme, sustain…

general practiceparamedicine
NSW2026-05-20

Inquest into the death of Mr Edward Curic aka Grahovac

49y · Male·Diabetes Mellitus and the Consequences thereof

Mr Edward Curic (49) died at Long Bay Correctional Complex on 21 May 2022 from diabetes mellitus and complications. He had poorly controlled Type 2 diabetes for 30 years with severe complications including bilateral ampu…

correctional healthgeneral medicinemethadone
NSWhospital2026-05-15

Inquest into the death of Robert Bell-Williams

71y · Male·metastatic papillary renal cell carcinoma

Robert Bell-Williams, aged 71, died from metastatic papillary renal cell carcinoma while in lawful custody at Long Bay Hospital on 1 February 2024. Imprisoned since 2012, he was diagnosed with renal cell carcinoma in 202…

oncologypalliative carecabozantinib
NSWhospital2026-05-14

Inquest into the death of Meirion Thomas Morris

67y · Male·Complications of chronic obstructive pulmonary disease

A 67-year-old man with end-stage chronic obstructive pulmonary disease was serving a lengthy prison sentence in Corrective Services NSW custody at Long Bay Hospital's Aged Care and Rehabilitation Unit. In early October 2…

correctional healthpalliative caremorphine
NSWaged care2026-05-14

Inquest into the death of Leonard John Warwick

78y · Male·Aspiration pneumonia on a background of advanced vascular dementia

Leonard John Warwick, 78, died on 14 February 2025 in Long Bay Hospital's Aged Care and Rehabilitation Unit while serving a life sentence without parole. He had advanced vascular dementia, hydrocephalus, type 2 diabetes,…

geriatric medicinepalliative caremorphine
VICaged care2026-04-30

Finding into death of Sandra Susan Black

54y · Female·Aspiration pneumonia secondary to Alzheimer's dementia complicating Down's Syndr…

Sandra Black, aged 54, died from aspiration pneumonia secondary to Alzheimer's dementia complicating Down Syndrome. She lived in specialist disability accommodation and had a long history of recurrent aspiration pneumoni…

general practiceemergency medicineantibiotics
TAScommunity2026-04-28

Coroner's Finding: Thompson, Damian Brian

71y · Male·Multiple injuries sustained in motorcycle crash

Damian Brian Thompson, aged 71, crashed his motorcycle on a rural road in Tasmania during torrential rain, sustaining severe injuries to his left leg and left hand. He was transported to Launceston General Hospital where…

emergency medicineintensive care
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
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
VIChospital2026-04-24

Finding into death of Mr JNY

Male·Pulmonary thromboembolism and bronchopneumonia secondary to deep vein thrombosis

JNY, a man with metastatic small cell carcinoma, COPD, and ischaemic heart disease, died from pulmonary thromboembolism and bronchopneumonia. He received palliative care at home provided by his partner PJN, who had undis…

palliative caregeneral practicesystemdesvenlafaxine
QLDhospital2026-04-14

Inquest into the death of Francis Michael Fahey

70y · Male·Metastatic melanoma with ischaemic heart disease as a contributing condition

Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…

oncologygeneral medicinesystemdelayimmunotherapy
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
WAhospital2026-04-14

Inquest into the Death of Wayne HARRIS

56y · Male·Complications of advanced metastatic sigmoid adenocarcinoma in an adult man with…

Wayne Harris was a 56-year-old Aboriginal man with advanced metastatic sigmoid adenocarcinoma who died in prison custody from complications of his terminal cancer. He was incarcerated for 11 years for child sex offences.…

oncologypalliative carecommunicationsystempalliative chemotherapy
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
VIChospital2026-04-07

Finding into death of Ronald Nieuwenhuis

65y · Male·Metastatic disease with gastrointestinal primary (adenocarcinoma)

Ronald Nieuwenhuis, a 65-year-old man with intellectual disability residing in supported accommodation, presented to hospital in January 2025 with abdominal pain and was found to have metastatic adenocarcinoma of gastroi…

emergency medicineradiology
VICcommunity2026-03-25

Finding into death of Daina Louise Clark

48y · Female·Complications of early onset dementia

Daina Louise Clark, aged 48, died from complications of early onset dementia at a specialist disability accommodation facility in June 2025. She had been diagnosed with early onset dementia in 2019 with an expected lifes…

neurologypalliative careclonazepam
NSWhospital2026-03-25

Inquest into the death of Lifa Faafete

69y · Male·advanced cholangiocarcinoma

Mr Lifa Faafete, aged 69, died from advanced cholangiocarcinoma while in remand custody at Metropolitan Special Programs Centre. He was appropriately transferred to Prince of Wales Hospital on 22 March 2025 for symptom m…

palliative careoncologycommunication
VIC2026-03-24

Finding into death of Robert Walter Burnett

85y · Male·Aspiration pneumonia in the setting of ischaemic heart disease, type 2 diabetes …

An 85-year-old man died of aspiration pneumonia in a prison healthcare setting while receiving palliative care. He had experienced a stroke two years prior resulting in cognitive decline and required assistance with all …

palliative caregeriatric medicinemetoclopramide
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