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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
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
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
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
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
VIChome2022-05-03

Finding into death of Carol Austin

65y · Female·Plastic bag asphyxia

Carol Austin, 65, died by plastic bag asphyxia at her home in Wangaratta in August 2018. She had a 20-year history of depression and had recently experienced suicidal ideation, a suicide attempt, and burns injury requiri…

psychiatrygeneral practicesystemcitalopram
VIC2022-03-21

Finding into death of Nilofer Nezami

38y · Female·Unascertained

Nilofer Nezami, a 38-year-old Victorian resident, died on 7 January 2019 following cosmetic surgery in Iran. She underwent multiple procedures including eye, breast, arm and abdominal surgery. Post-operatively, she devel…

plastic and reconstructive surgeryanaesthesiasystemproceduralmorphine
VIChospital2022

Finding into death of Ms S

63y · Female·Sepsis complicating cellulitis following skin cancer excision and skin graft pro…

A 63-year-old woman died from sepsis complicating cellulitis following elective skin cancer excision and skin graft performed in a general practitioner's clinic. The lesion was a squamous cell carcinoma (invasive Bowen's…

general practiceplastic and reconstructive surgeryantibiotics
VIChospital2020-07-07

Finding into death of Marek Koziol

61y · Male·Injuries sustained in motor vehicle collision (pedestrian)

A 61-year-old legally blind man was struck by a motor vehicle while crossing a busy highway with his guide dog. He sustained severe head injuries including subarachnoid and subdural haemorrhage, and diffuse axonal injury…

trauma surgeryintensive care
VIChospital2019-08-01

Finding into death of Tyla Jade Hovenbitzer

18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…

An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…

paediatricsgeneral practicesystemdelaytemazepam
VIChospital2018-08-31

Finding into death of David William Lobb

53y · Male·Complications of burns sustained in a blast

A 53-year-old qualified boiler maker died from complications of severe burns sustained in a gas explosion. While attempting to remove a refrigeration compressor from a hotel cellar with an unqualified colleague, they cut…

intensive caretrauma surgeryproceduralsystem
VIChome2017-12-04

Finding into death of Leigh Thomas Aiple

31y · Male·Pulmonary thromboembolism

A 31-year-old man with obesity (BMI 40.2) and sleep apnoea underwent extensive cosmetic surgery in Malaysia (liposuction, abdominoplasty, chest lipectomy, and subsequent facial procedures) across two operations within fi…

plastic and reconstructive surgerygeneral surgerydiagnosticmedicationenoxaparin
VIChospital2015-10-30

Finding into death of Avjit Singh

31y · Male·Complications of burns

Avjit Singh died from complications of extensive burns (95% of body) sustained during a violent incident on 4 October 2012. He had been involved in a relationship with domestic violence and control, including alleged rap…

emergency medicineintensive care
VIChospital2015-03-03

Finding into death of Matthew Jack Whyte

3y · Male·Brainstem ischaemia in association with Arnold Chiari malformation

Matthew Whyte, a 3-year-old with Arnold Chiari malformation and hydrocephalus, died from brainstem ischaemia following multiple shunt complications and emergency decompression surgery. The coroner found that after Matthe…

neurosurgeryplastic and reconstructive surgerydiagnosticcommunication
VIChospital2014-09-11

Finding into death of Daniel Raymond Cowan

15y · Male·global hypoxic cerebral injury following medical intervention for high velocity …

Daniel Cowan, aged 15, sustained a penetrating head injury from a homemade air gun while with friends. Despite appropriate emergency response and comprehensive multidisciplinary medical management at Royal Children's Hos…

neurosurgeryintensive caremidazolam
VIChospital2012-09-11

Finding into death of Robert Anderson

50y · Male·Complications of right buttock necrotising fasciitis secondary to chronic right …

50-year-old male with chronic pain from jockey injuries became dependent on morphine. General practitioner prescribed intramuscular (IM) morphine for self-administration at home from 2005–2007 at doses of 120–240mg daily…

general practicepsychiatrydiagnosticmedicationmorphine sulphate
VIChospital2012-04-05

Finding into death of Abdullah Kocoglu

4y · Male·Complications of cutaneous thermal burn injuries

Abdullah Kocoglu, age 4, died from complications of severe thermal burn injuries sustained in a house fire on 14 February 2011 at his grandparents' home in Hampton Park, Victoria. The fire was ignited when Abdullah playe…

plastic and reconstructive surgeryintensive caresystemdelay
VIChospital2012-02-22

Finding into death of Ellen Mary OConnor

90y · Female·Renal failure secondary to gentamicin therapy for urinary tract infection (sepsi…

Ellen O'Connor, a 90-year-old woman with renal artery stenosis and coronary artery disease, died from acute renal failure following gentamicin administration for Pseudomonas aeruginosa urinary tract infection. A single 2…

orthopaedic surgeryplastic and reconstructive surgerymedicationdiagnosticgentamicin

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