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SAhospital2026-03-30

Coroner's Finding: Chadha, Hemant and Battagodage, Sachintha Nandula

Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…

Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…

emergency medicinegeneral practicediagnosticcommunicationdiazepam
SAcommunity2026-03-26

Coroner's Finding: Shepley, Adam Troy

30y · Male·Unascertained; likely cardiac arrhythmia

Adam Troy Shepley, aged 30, died in police custody following restraint after climbing onto roofs while displaying drug-affected and paranoid behaviour. Post-mortem examination revealed an unascertained cause, likely a ca…

emergency medicineparamedicinediagnosticcommunicationmethamphetamine
SAhospital2026-02-26

Coroner's Finding: Lowery, Nahuel Sebastian

41y · Male·Acute liver failure with contributing Castleman's disease

A 41-year-old Aboriginal man with HIV and Castleman's disease died from acute liver failure while on home detention. He had variable compliance with antiretroviral therapy, exacerbated by amphetamine use disorder and men…

infectious diseasesintensive careantiretroviral therapy
SAhospital2026-02-26

Coroner's Finding: Taylor, Warren Richard

79y · Male·Urinary tract infection with E coli bacteraemia on a background of ischaemic hyp…

A 79-year-old man with multiple comorbidities attended Whyalla Hospital ED following a fall. Paramedics documented concerning vital signs (tachypnoea, tachycardia, low oxygen saturation, fever) and a history suggestive o…

emergency medicinegeneral practicediagnosticcommunicationtrimethoprim
SAcommunity2025-11-27

Coroner's Finding: Hudson, Simon

41y · Male·unascertained, in circumstances of methylamphetamine intoxication, extreme physi…

Simon Hudson, a 41-year-old man, died following a physical altercation with an intoxicated youth on a city street. After the five-minute fight, police arrived and arrested both parties. Hudson became unresponsive shortly…

forensic medicineemergency medicinemethamphetamine
SAhospital2025-07-31

Coroner's Finding: Panella, Anna Vincenza and Skeffington, Bernard Anthony and Jessett, Graham Henry

Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…

Three South Australians died following extended waits on ambulance ramps outside metropolitan hospitals. Anna Panella (76) died from pulmonary thromboembolism; Bernard Skeffington (89) died from aspiration pneumonia afte…

emergency medicinecardiologycommunicationsystem
SAhospital2025-06-11

Coroner's Finding: OHalloran, Emma Louise

48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam

A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…

cardiologygeneral practicesystemcommunicationflecainide
SA2025-05-20

Coroner's Finding: Pham, Duy Ngoc

35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…

35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…

emergency medicinegeneral practicedelaycommunicationmethamphetamine
SAhospital2024-03-27

Coroner's Finding: Collins, Jennifer Ann

30y · Female·tricuspid valve bacterial endocarditis

Jennifer Collins, a 30-year-old intravenous methylamphetamine user, died from tricuspid valve bacterial endocarditis on 6 September 2018. She presented to Noarlunga Hospital ED on 20 August 2018 with chest tightness, fev…

emergency medicinecardiologydiagnosticcommunicationmethamphetamine
SAcommunity2023-10-13

Coroner's Finding: Adams, Michael Gerard

62y · Male·cardiac arrest complicating psychotic episode

Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applie…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
SAcommunity2023-05-26

Coroner's Finding: Latouche Mazzei, Lucas

5y · Male·acute upper airway obstruction from nectarine stone

Lucas Mazzei, aged 5 years, died on 27 March 2017 from acute upper airway obstruction caused by an uncut nectarine stone. While attending school, he was separated from his class during a science lesson and left watching …

emergency medicinepaediatricscommunicationsystemlamotrigine
SAhome2022-12-16

Coroner's Finding: Reid, Paul

50y · Male·ischaemic heart disease

Paul Reid, a 50-year-old Aboriginal man with severe ischaemic heart disease and poor medication compliance, died of a cardiac arrhythmia during his arrest by South Australian Police. He was highly intoxicated (BAC 0.25%)…

cardiologyforensic medicinediagnosticsystemalcohol
SA2021-06-02

Coroner's Finding: DUFFIELD Clinton John

35y · Male·unascertained - multifactorial cardiorespiratory arrest

A 35-year-old male died in police custody following arrest for dangerous driving and property damage. He displayed acute psychotic behaviour with paranoia, aggression, and 'super-strength' during restraint. Post-mortem e…

forensic medicineemergency medicinecannabis
SA2020-05-08

Coroner's Finding: CANHAM Craig Nicholas

63y · Male·cardiac arrhythmia complicating recent posterior myocardial infarct with underly…

Craig Nicholas Canham, aged 63, died in custody at Yatala Labour Prison from cardiac arrhythmia complicating a recent posterior myocardial infarction with underlying hypertrophic cardiomyopathy. He had suffered a myocard…

cardiologygeneral practicetenecteplase
SAaged care2019-06-12

Coroner's Finding: SINCLAIR Colin George

68y · Male·Obstruction of airways by foodstuffs with contributing alcohol-related dementia

Colin George Sinclair, aged 68, died from airway obstruction by food while in high-level aged care under guardianship. He had alcohol-related dementia and Korsakoff's syndrome with significant cognitive decline affecting…

geriatric medicinespeech pathology
SA2019-05-09

Coroner's Finding: PIKE Lucas Adam

43y · Male·morphine (heroin) toxicity

Lucas Pike, aged 43, died from heroin toxicity after injecting heroin in a general practitioner's surgery in Adelaide. The heroin was procured by Mark Campbell and administered by Campbell in the practice's pathology roo…

general practiceemergency medicineheroin
SAhospital2018-07-12

Coroner's Finding: MITCHELL Wayne Brian

49y · Male·ischaemic heart disease with coronary artery thrombosis (left main stem coronary…

Wayne Mitchell, a 49-year-old man, presented to a clinic with acute chest pain radiating to his jaw, accompanied by dizziness, diaphoresis, and dyspnoea. His symptoms resolved before ambulance arrival. The paramedics per…

cardiologyemergency medicinediagnosticcommunication
SAcommunity2018-02-23

Finding into death of Alexander Sheng Wei Li

16y · Male·Heat related illness in an individual with enterovirus D68 infection

Alexander Li, a 16-year-old with underlying enterovirus D68 infection, died of heat-related illness during a school bushwalking expedition in remote South Australia in extremely hot conditions (temperatures reaching 39.1…

emergency medicineparamedicinesystemcommunication
SA2018-01-30

Coroner's Finding: JONES Heath Ryan

35y · Male·hypoxic-ischaemic encephalopathy (post cardiac arrest) on a background of acute …

A 35-year-old man died by hanging in a medium-security prison while on remand. He was found unresponsive in his cell with a ligature around his neck. Despite immediate CPR, transfer to hospital and transfer to ICU at Fli…

emergency medicineintensive caresystemmethamphetamine
SA2015-06-24

Coroner's Finding: HARDING-ROOTS Jeremy Godfrey

47y · Male·Toxic effects of phosphine gas

Jeremy Harding-Roots died from phosphine gas toxicity after deliberately exposing himself to the pesticide fumigant aluminium phosphide (Fumitoxin) during a siege at his former girlfriend's residence. Key clinical and pr…

psychiatrygeneral practicediagnosticsystemoxazepam

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