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VIChospital2026-07-27

Finding into death of Alan Gordon Wolstenholme

72y · Male·Complications of suspected upper gastrointestinal tract haemorrhage, hospital ac…

A 72-year-old man with metastatic squamous cell lung cancer and multiple serious comorbidities was admitted to Ballarat Hospital in July 2024 with lethargy, fatigue, and rapid atrial fibrillation. Due to medication chart…

cardiologyemergency medicinemedicationsystembuprenorphine
VICcommunity2026-07-08

Finding into death of Linda Joy Bridle

72y · Female·Combined drug toxicity (tapentadol, fluoxetine)

Linda Joy Bridle, 72, died from combined drug toxicity (tapentadol and fluoxetine) with a contributing subdural haemorrhage. She had multiple chronic conditions including heart failure and chronic pain, managed through c…

general practicepharmacymedicationcommunicationtapentadol
TAS2026-06-03

Coroner's Finding: Brown, Nicholas, Wiki, Toni, Winwood, Matthew and Kemp, Belinda

Male, female, male, female·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …

Joint inquest into four deaths of individuals prescribed opioid replacement therapy by Dr J. between September 2016 and August 2017: Nicholas Shane Brown (35), Toni Lee Wiki (38), Matthew Wayne Winwood (47), and Belinda …

addiction medicinegeneral practicediagnosticmedicationmethadone
VIChospital2026-02-12

Finding into death of Kristy Ann Mitchener

45y · Female·Complications of sepsis secondary to sacral pressure wound in a woman with genet…

Kristy Ann Mitchener, a 45-year-old woman with severe intellectual disability, genetic developmental and epileptic encephalopathy, and oesophageal dysmotility, died from sepsis secondary to a sacral pressure ulcer despit…

general practiceemergency medicinesystemcommunicationantibiotics
TAScommunity2026-01-13

Coroner's Finding: Joshua James Tyrrell

28y · Male·Multiple head, facial and spinal injuries sustained in a single vehicle motorbik…

Joshua Tyrrell, 28, died from multiple head, facial and spinal injuries sustained in a motorbike crash on the Brooker Highway. He was riding at excessive speed and failed to maintain steering control through a bend. Toxi…

general practiceemergency medicinemedicationcommunicationdiazepam
NSW2025-12-08

Inquest into the death of Benjamin Cullen

41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…

Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from P…

neurologyemergency medicinemedicationsystemlevetiracetam
QLDhome2025-10-17

Inquest into the death of Alexandria Catherine Forrester

39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…

A 39-year-old woman with opioid dependency died from cardiac arrest caused by methadone toxicity. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatmen…

addiction medicinegeneral practicediagnosticmedicationmethadone
VIC2025-08-18

Finding into death of Wilhelm Bruno Mueller

69y · Male·Ischaemic and hypertensive heart disease

Wilhelm Mueller, a 69-year-old prisoner at Middleton Prison, died suddenly from ischaemic and hypertensive heart disease. Autopsy revealed critical coronary artery stenosis (>75%) with cardiac hypertrophy and remote myoc…

cardiologygeneral practicegliclazide
VICmental health2025-07-24

Finding into death of Mr SWX

32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity

A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …

psychiatryemergency medicinemedicationcommunicationolanzapine
VIChospital2025-03-03

Finding into death of Caroline Anne McCormack

74y · Female·Infective exacerbation of chronic obstructive airways disease in the setting of …

Caroline McCormack, 74, died from infective exacerbation of chronic obstructive airways disease following a medication administration error where pregabalin was erroneously included in her Webster-pak despite being cease…

general practicepalliative caremedicationsystempregabalin
TAShospital2024-09-30

Coroner's Finding: Newell, Warren James

71y · Male·raised intracranial pressure caused by left frontal-temporal-parietal subdural h…

Warren James Newell, a 71-year-old man with oesophageal cancer, presented with acute coronary syndrome on 29 September 2022 and was appropriately diagnosed and treated with anticoagulation and dual antiplatelet therapy. …

cardiologyemergency medicinemedicationsystemenoxaparin
ACThospital2024-09-16

Inquest Into The Death Of Sharyn Kaine

73y · Female·Multi organ failure due to adhesions related bowel perforation (surgically treat…

Sharyn Kaine, a 73-year-old woman, died from multi-organ failure due to adhesions-related bowel perforation and paracetamol-induced liver failure. She was prescribed intravenous paracetamol 1g four times daily post-opera…

general surgeryanaesthesiamedicationtranscriptionparacetamol
QLDhospital2024-08-13

Non-inquest findings into the death of RJH

70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide card…

A 70-year-old woman with complex cardiac history including heart failure, paroxysmal atrial fibrillation, and coronary atherosclerosis presented with urinary tract infection and atrial fibrillation on Christmas Day 2021.…

cardiologyemergency medicinediagnosticmedicationflecainide
NSWhome2024-03-26

Inquest into the death of MO

6y · Unknown·methadone toxicity

A 6-year-old boy died from methadone toxicity after ingesting his parents' takeaway methadone mixed in juice at home. Both parents were on the NSW Opioid Treatment Program (OTP). The prescribing physician increased metha…

addiction medicinepaediatricsdiagnosticcommunicationmethadone
WAhospital2023-11-17

Inquest into the Death of Child MD (Name Subject to a Suppression Order)

2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…

A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…

intensive carepaediatricsmedicationceftriaxone
VIC2023-10-30

Finding into death of Darren James Fielding

29y · Male·Methadone toxicity

Darren James Fielding died in custody at Middleton Prison on 26 May 2018 from methadone toxicity. He was on day 6 of opioid substitution therapy (OSTP) when he received his prescribed 10mg methadone dose. Expert evidence…

pharmacycorrectional healthmedicationsystemmethadone
TAShospital2023-10-11

Coroner's Finding: Jones, Emily Margaret Rose

82y · Female·traumatic closed head injury (subdural haematoma) resulting from a fall from sta…

Mrs Emily Jones, 82, died from subdural haematoma following an unwitnessed fall at Royal Hobart Hospital on 15 November 2021. She was admitted five days after discharge from Hobart Private Hospital where she was treated …

cardiologyemergency medicinemedicationcommunicationmetoprolol
TAShome2023-07-24

Coroner's Finding: QD de-identified

45y · Female·combined drug (tapentadol, nortriptyline, venlafaxine, codeine, oxycodone, queti…

QD, a 45-year-old woman with significant comorbidities including obesity, obstructive sleep apnoea, COPD, depression, and substance abuse history, died from mixed drug and alcohol intoxication. Toxicology revealed toxic/…

general practicepsychiatrydelaysystemtapentadol
TAShome2023-05-25

Coroner's Finding: CE de-identified

69y · Male·amitriptyline and alcohol toxicity with ischaemic heart disease

A 69-year-old man with longstanding anxiety, depression, heavy alcohol use, and multiple prior intentional overdoses of amitriptyline died from combined amitriptyline and alcohol toxicity with underlying ischaemic heart …

psychiatrygeneral practicesystemcommunicationamitriptyline
VICaged care2023-03-22

Finding into death of S M

91y · Male·Complications of cerebrovascular and ischaemic heart disease in a man post anaph…

A 91-year-old man with known diltiazem allergy was prescribed diltiazem by a geriatrician despite documented allergy records. The geriatrician relied on the patient's verbal denial of allergies despite significant dement…

geriatric medicinegeneral practicediagnosticmedicationdiltiazem

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