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VIChome2026-03-04

Finding into death of Carol Fay Slade

54y · Female·Severe burns sustained in a house fire (palliated)

Carol Fay Slade, a 54-year-old woman with acquired brain injury from a 2003 motorcycle accident and mobility limitations, died from severe burns sustained in a house fire at her public housing property in Shepparton. The…

emergency medicineintensive caresystemmethadone
TAShome2026-02-17

Coroner's Finding: Gregory and Diane Burkhalter

73y · Male·Gregory Frank Burkhalter: carbon monoxide toxicity due to inhalation of carbon m…

Two elderly US-born residents died in a house fire caused by a 120-volt electric blanket operating on Australia's 230-volt grid, resulting in insulation failure and combustion. Mr Burkhalter (73) died from carbon monoxid…

emergency medicineanaesthesiasystem
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
QLDhospital2025-10-23

Inquest into the death of Shirley Elizabeth Haggett

78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…

78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…

anaesthesiaplastic and reconstructive surgerysystemdiagnosticmidazolam
SAhospital2025-07-03

Coroner's Finding: Cheesman, Trevor Allan

70y · Male·complications arising from craniofacial resection and orbital exenteration for r…

A 70-year-old man died following complex craniofacial resection and orbital exenteration for right sinonasal adenocarcinoma. Multiple surgical complications occurred including carotid artery injury, cerebral infarction, …

neurosurgeryENT surgerysystemolanzapine
QLDhospital2025-03-14

Non-inquest findings - a 5 year old boy

5y · Male·Complications of burns

A 5-year-old boy died from complications of severe burns sustained during a fuel ignition incident at his father's rural property. While refuelling a small motorcycle, the father failed to shut off the engine and did not…

plastic and reconstructive surgeryintensive careprocedural
TAShospital2025-01-29

Coroner's Finding: de-identified IM

37y · Female·sepsis due to necrotising fasciitis following abdominoplasty with liposuction

A 37-year-old woman died from sepsis due to necrotising fasciitis following abdominoplasty and liposuction. She was discharged on post-operative day 4 with severe pain, nausea, and vomiting, which were attributed to norm…

plastic and reconstructive surgerygeneral practiceoxycodone
VIChospital2024-11-19

Finding into death of Daniel Surtees

36y · Male·Complications of thermal burn injuries

Daniel Surtees, aged 36, died from complications of extensive thermal burn injuries (>80% body surface area) sustained during a domestic violence incident. After consuming 14 cans of bourbon at a party, Daniel returned h…

plastic and reconstructive surgeryintensive caremorphine
QLDaged care2024-10-10

Non-inquest findings into the death of Diane Margaret Crowther

76y · Female·multiple organ failure due to abdominal wall cellulitis (surgically treated)

Mrs Crowther, a 76-year-old obese woman with multiple comorbidities in residential aged care, died from multiple organ failure secondary to abdominal wall cellulitis. A critical care failure occurred when an old dressing…

geriatric medicineplastic and reconstructive surgerydiagnosticcommunicationhydrozole cream
VIChospital2024-09-26

Finding into death of FH C

11y · Male·Sepsis

An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…

emergency medicinepaediatricsdiagnosticcommunicationrisperidone
WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat f…

psychiatryintensive carecommunicationsystempaliperidone
NSWhospital2024-03-28

Inquest into the death of Monika Chetty

39y · Female·Complications from burns, such burns being from acid doused over 80% of Ms Chett…

Monika Chetty, aged 39, died from complications of severe acid burns covering 80% of her body sustained in early December 2013. She was found in bushland in West Hoxton on 4 January 2014 and died 27 days later at Concord…

plastic and reconstructive surgeryemergency medicinediagnosticsystem
NSWhospital2023-10-31

Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…

Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…

intensive careanaesthesiadiagnosticproceduralrocuronium
VIChospital2023-10-30

Finding into death of K K

40y · Male·Full thickness burns to body in the setting of self-immolation

A 40-year-old Tamil asylum seeker died from full thickness burns sustained during self-immolation on 20 August 2021. The death occurred three days after Victoria Police attended a family violence incident where KK assaul…

emergency medicineplastic and reconstructive surgerycommunicationsystemmorphine
VIChospital2023-10-06

Finding into death of G A

86y · Female·Bradycardic arrest secondary to relative hypoperfusion while undergoing surgery …

An 86-year-old woman underwent elective surgery to excise a probable squamous cell carcinoma from her left hand with split-thickness skin grafting under local anaesthesia with intravenous sedation. She suffered an unexpe…

dermatologyplastic and reconstructive surgerymedicationpropofol
VIChospital2023-07-06

Finding into death of Michael Alan Holmes

34y · Male·effects of burns

Michael Holmes, 34, died from severe burns sustained when he re-entered a burning house attempting to rescue his son. The fire originated from clothes and towels left drying on a rack in front of an unattended wood heate…

emergency medicinetrauma surgerysystemfentanyl
QLDcommunity2023-04-05

Grimes, William George

31y · Male·Burns

31-year-old George Grimes with longstanding schizophrenia was found threatening self-immolation after consuming alcohol and missing antipsychotic medication. Despite police de-escalation attempts, he doused himself with …

psychiatryemergency medicinediagnosticcommunicationquetiapine
TAShospital2022-09-19

Coroner's Finding: Tommerup, Daniel James

51y · Male·multi-organ failure due to acute kidney injury and haemodynamic shock as a conse…

A 51-year-old man with significant alcohol intoxication sustained thermal burns affecting over 60% of body surface area when he accidentally set fire to himself while homeless. He was transported from Launceston General …

emergency medicineplastic and reconstructive surgeryalcohol
TAShome2022-08-04

Coroner's Finding: Joyce. Kaye Maree

58y · Female·thermal burns

A 58-year-old woman with schizophrenia died from extensive thermal burns after a fire originated in a wall-mounted heat pump that lacked a required residual current device (RCD). The heat pump was installed in 2012 witho…

psychiatrygeneral practicesystempaliperidone
QLDhospital2022-07-08

R - Non-inquest findings

0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…

A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…

anaesthesiaintensive carediagnosticproceduralpropofol

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