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VICmental health2025-11-11

Finding into death of Graziano Birgi

An 86-year-old man with treatment-resistant paranoid schizophrenia residing in a secure psychiatric unit died from oesophageal perforation. He experienced two unwitnessed falls on 20 October 2024 and declined post-fall m…

psychiatrygeriatric medicine
VIChome2025-11-11

Finding into death of RBJ

A 26-year-old man died from suffocation after intentional recreational nitrous oxide use via a full-face gas mask connected to a cream whipper dispenser. He had purchased 300 cream chargers plus a 640g tank online two da…

forensic medicinepublic healthnitrous oxide
VICcommunity2025-11-11

Finding into death of Veronica Norah Cheney

Veronica Cheney disappeared on 1 March 1945 at age 43 from Melbourne. She had a significant psychiatric history including hospitalisation for psychosis and auditory hallucinations at Royal Park and Mont Park asylums in 1…

psychiatrypathology
VIC2025-11-10

Finding into death of Andrew Phillip John Kursinskis

Andrew Kursinskis, a 57-year-old man with intellectual disability, dysphagia, autism, epilepsy and pica, died from complications following aspiration of chicken schnitzel while living in supported disability accommodatio…

speech pathologyemergency medicinesystemcommunicationlevetiracetam
VICcommunity2025-11-10

Finding into death of Ayman Peter Fatho

A 31-year-old male died from a gunshot wound to the chest inflicted during a violent confrontation. The deceased had stalked and threatened the shooter following an unfounded belief that the shooter was romantically invo…

methylamphetamine
VIChospital2025-11-10

Finding into death of Panayotis (Peter) Pavlis

An 83-year-old man remanded in custody at Ravenhall Correctional Centre died of pneumonia in St Vincent's Hospital. He had rapidly progressive dementia since 2021, was immobile and bedbound in his final six months, and h…

emergency medicinepalliative care
VICED2025-11-10

Finding into death of Jason Hosier

Jason Hosier, a 39-year-old man with complex mental health and substance use history, died from mixed drug toxicity following discharge from Sunshine Hospital. He was subject to an inpatient temporary treatment order and…

emergency medicinepsychiatrycommunicationsystemmethadone
VICcommunity2025-11-07

Finding into death of Chieu Kheang Chua

A 40-year-old male drowned at Point Roadknight Beach while rock fishing at night with friends. He was knocked into the ocean by a large wave or slipped on the wet, uneven rock shelf. The group was not wearing personal fl…

VIC2025-11-06

Finding into death of Gensheng Zhao

A 56-year-old man drowned while snorkelling and freediving off Seal Island in Bass Strait. He was wearing a weighted belt without a buoyancy compensation device or emergency flotation aid, which made it difficult to rema…

forensic medicine
NSWcommunity2025-11-06

Inquest into the death of Simone Strobel

25-year-old German national Simone Strobel was found dead on 17 February 2005 near Lismore, NSW, covered with palm fronds. She died between midnight and 5:30am on 12 February 2005 following an argument with her boyfriend…

forensic medicinetoxicologycannabis
ACThospital2025-11-05

Inquest Into The Death Of Ms Tl A Pseudonym

A 19-year-old woman died from multiple injuries sustained in a motor vehicle collision on Black Mountain Drive, Canberra on 4 June 2022. She was driving a 1986 Toyota sedan at approximately 80 km/h when she lost control …

emergency medicinetrauma surgery
SAhospital2025-11-05

Coroner's Finding: Jackson, Dennis Charles

Dennis Jackson, a 67-year-old from Broken Hill, underwent left upper lobe lobectomy based on a falsely positive lung biopsy contaminated with squamous cell carcinoma tissue from another patient during processing at SA Pa…

cardiothoracic surgerypathologydiagnosticsystem
NSW2025-11-05

Inquest into the death of Amar Dk Kattola

Amar Dk Kattola, aged 34, was shot and killed by two unknown assailants in the garage of his Fairfield apartment on 10 January 2021. He suffered multiple gunshot wounds in a targeted attack that occurred at 2:27 am. Desp…

WAhospital2025-11-05

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

An eight-month-old boy in state care died from Streptococcus pyogenes and parechovirus infection. He presented to hospital twice before death with fever and ear infection symptoms. On first presentation (2 September), he…

emergency medicinegeneral practiceparacetamol
VIChome2025-11-04

Finding into death of Kon Maximos

Kon Maximos, aged 62, died from a self-inflicted shotgun wound to the head on 15 October 2023. He was in acute interpersonal crisis following marital separation, family estrangement over infidelity, and police interventi…

psychiatrypsychologydiagnosticcommunicationmirtazapine
NSWcommunity2025-11-03

Inquest into the death of JF

JF, a 60-year-old woman with recurrent major depressive disorder and a history of suicide attempts, died by suicide at Redhead Headland on 12 February 2024. Despite three prior psychiatric hospitalizations and documented…

psychiatrygeneral practicesystemMirtazapine
NSWcommunity2025-10-31

Inquest into the disappearance and suspected death of Sana Salman

Sana Salman, a 34-year-old woman with bipolar disorder and schizoaffective disorder, went missing on 1 September 2022 after being discharged from Northern Beaches Hospital on 22 August 2022. She had been admitted for a p…

psychiatrysystemcommunicationclozapine
QLD2025-10-29

Inquest into the death of Selesa Tafaifa

Selesa Tafaifa, a 44-year-old woman with Samoan heritage, died in custody at Townsville Women's Correctional Centre on 30 November 2021 during physical restraint by correctional officers, including application of a safet…

forensic medicineemergency medicineproceduralsystemMixtard 30/70 insulin
VIC2025-10-29

Finding into death of David James Klingberg

David Klingberg, a 55-year-old experienced pile testing engineer, died from traumatic head injury sustained when an auxiliary line hook on a piling rig struck him in the face at a construction site. The hook became jamme…

emergency medicineintensive caresystemmorphine
VIChospital2025-10-28

Finding into death of Jean Elizabeth Crocker

A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …

emergency medicinegeneral medicinemedicationdiagnosticwarfarin
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