Coronial
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VICcommunityNew2026-08-25

Finding into death of Garry William Ledger

78y · Male·Complications of acute renal impairment in the setting of pelvic and lumbar frac…

Garry Ledger, 78-year-old South Australian visitor, died three weeks after falling on a Melbourne tram on 28 August 2025. While boarding tram route 16, he fell during tram acceleration while using his Myki card and befor…

trauma surgerygeriatric medicinewarfarin
SAaged careNew2026-08-21

Coroner's Finding: Clark, Wayne Malcolm

84y · Male·bronchopneumonia complicating C2 odontoid fracture (palliated) due to fall on a …

Wayne Malcolm Clark, aged 84, with advanced Alzheimer's and vascular dementia, fell in a secure residential aged care facility and sustained a C2 odontoid fracture. He died on 23 August 2023 from bronchopneumonia complic…

general practiceparamedicineparacetamol
VIChomeNew2026-08-20

Finding into death of Gayle Patricia Carley

77y · Female·Ischaemic heart disease

Gayle Patricia Carley, 77, collapsed unwitnessed at home with acute ischaemic heart disease on 19 October 2023. Ambulance paramedics arrived and initiated emergency treatment, but a MICA paramedic inadvertently administe…

emergency medicineparamedicinemedicationsystemmetaraminol
VIChomeNew2026-08-20

Finding into death of Dorothy Boag

91y · Female·Aspiration pneumonia in a woman with multiple co-morbidities

91-year-old woman with disability living in specialist disability accommodation who died from aspiration pneumonia. She had documented moderate oropharyngeal dysphagia from prior stroke, managed with pureed diet and thic…

general practicegeriatric medicine
VICcommunityNew2026-08-17

Finding into death of Guy Christian Mason

48y · Male·Pulmonary thromboembolism

Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…

emergency medicinegeneral surgerydiagnosticsystemenoxaparin
NTcommunityNew2026-08-14

Inquest into the death of Road death 57 of 2024

47y · Male·Multiple blunt force injuries to the neck, chest and lower limbs sustained in a …

A 47-year-old male passenger died from multiple blunt force injuries (bilateral pneumothoraces, pulmonary contusions, ruptured spleen, pelvic fractures, cervical spine fracture with spinal cord haemorrhage) from a high-s…

emergency medicineforensic medicinesystemmethamphetamine
SAhome2026-08-12

Coroner's Finding: Sylvia, Kate Marie

32y · Female·cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage

Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. mis…

paramedicinegeneral medicinediagnosticcommunicationoral contraceptive pill
NSWhome2026-08-10

Inquest into the death of SMS

14y · Female·unascertained natural causes – possibly encephalitis leading to seizure or sudde…

SMS, a 14-year-old previously healthy girl, collapsed unexpectedly at home on 10 October 2021 and was found unresponsive and not breathing. Immediate resuscitation was commenced by family members and emergency services, …

emergency medicineintensive care
ACThome2026-08-03

Inquest into the death of Felipe Esteban Alvarez (No 2)

Male·toxicity caused by a combination of methylamphetamine and morphine

Felipe Esteban Alvarez died on 30 March 2021 from toxicity caused by methylamphetamine and morphine (heroin) ingestion at his unit in Taylor, ACT. He collapsed after self-injecting heroin in the presence of others, inclu…

addiction medicineemergency medicinedelayproceduralheroin
VICcommunity2026-07-27

Finding into death of DH I

37y · Male·Multiple injuries sustained in a train incident

A 37-year-old Aboriginal man with chronic opioid use disorder and co-occurring mental health issues presented to Royal Melbourne Hospital's Mental Health, Alcohol and Other Drugs Hub after being found slumped in Melbourn…

emergency medicineaddiction medicinesystemheroin
VICcommunity2026-07-23

Finding into death of John Kieran Holland

63y · Male·Drowning

John Kieran Holland, a 63-year-old Irish visitor, drowned while swimming at Hutt Gully Beach, an unpatrolled and hazardous beach on Victoria's Great Ocean Road, on 1 January 2024. Despite knowing how to swim, Mr Holland …

emergency medicineparamedicinemirtazapine
QLDhome2026-07-20

Non-inquest findings into the death of Baby M

Female·Meconium aspiration syndrome

Baby M was born at home via unattended free birth after her mother had previously undergone caesarean section. The mother experienced rupture of membranes one day before labour and was at 42 weeks gestation, both risk fa…

obstetricsmidwiferysystem
SAhome2026-07-13

Coroner's Finding: Low, David John

64y · Male·ischaemic and hypertensive heart disease (operated) with cardiomegaly with contr…

A 64-year-old man with ischaemic heart disease, cardiomegaly, diabetes and obesity died at home from cardiac failure after calling his care worker for assistance. A paramedic arrived but refused to force entry, instead a…

cardiologyparamedicinesystemdelay
VICcommunity2026-07-08

Finding into death of W Q

18y · Male·Head injuries sustained in a motorbike incident

WQ, aged 18, died from head injuries sustained in a motorcycle accident on 31 December 2024 in the Alpine National Park near Licola, Victoria. After consuming significant quantities of alcohol (blood alcohol 0.14 g/100mL…

emergency medicineintensive carealcohol
QLD2026-07-07

Inquest into the death of Clifford Raymond Grogan

68y · Male·Atherosclerotic cardiovascular disease

Clifford Raymond Grogan, a 68-year-old First Nations man, died from atherosclerotic cardiovascular disease while in custody at Lotus Glen Correctional Centre on 11 May 2023. He had significant pre-existing cardiac diseas…

cardiologygeneral medicine
VICcommunity2026-07-01

Finding into death of VNP

41y · Female·Injuries sustained in a fall from a height

VNP was a 41-year-old woman with longstanding bipolar disorder type 1, chronic pain from endometriosis, and substance misuse history who died by suicide on 10 July 2023. She had experienced homelessness, family estrangem…

general practicepsychiatryalcohol
WAhome2026-06-29

Inquest into the Death of David William LAVARS

Male·phosphine toxicity in a man with atherosclerotic heart disease

Robert Lavars died on 6 September 2022 after deliberately ingesting aluminium phosphide tablets while under police arrest at his home in Shoalwater. He had serious health conditions including strokes, heart disease, and …

toxicologyparamedicineproceduralcommunicationaluminium phosphide
QLDcommunity2026-06-26

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
VIChome2026-06-26

Finding into death of Kerrie Terese Berlowitz

78y · Female·Hypernatraemia in the setting of lowered oral intake

Kerrie Berlowitz, 78, with cerebral palsy and intellectual disability, died of hypernatraemia (severe sodium elevation) due to dehydration. Living in supported disability accommodation in Carrum, she progressively refuse…

general practicedietetics
VIChome2026-06-24

Finding into death of Sheridan Louise Burnell

24y · Female·Mixed drug toxicity

Sheridan Burnell, 24, died from mixed drug toxicity following an intentional overdose of prescription medications (lamotrigine and quetiapine) on 2 January 2021. Her mental health care was reasonable and appropriate. The…

psychiatrygeneral practicecommunicationsertraline
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