Graham Keith Moore, a 57-year-old man with Down syndrome and early Alzheimer's dementia, died of pneumonia at Bendigo Hospital on 11 February 2025. He resided in specialist disability accommodation and received NDIS-fund…
Narelle Simmons, 42, died from haemothorax and pneumonia secondary to rib fractures, with contributing factors of hepatic cirrhosis, chronic alcoholism, and multiple drugs (methadone, methylamphetamine, diazepam, sertral…
Peter Owen Pilkington, 48, died from a gunshot wound sustained during a police siege on 6 December 2021. After escalating behaviour at his NDIS support office in Stretton, Queensland, Peter produced what police believed …
Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nau…
Richard Paul Atkins, a 65-year-old man with intellectual disability and epilepsy living in specialist disability accommodation, died from ischaemic heart disease. Post-mortem examination revealed moderate to severe tripl…
A 16-year-old male died from massive chest, abdominal and pelvic injuries sustained in a quad bike crash. The quad bike's right rear wheel detached during riding due to incorrect fitting of after-market wheels using wron…
Craig Anthony Twining, aged 61, died from multiple injuries sustained in a two-vehicle head-on collision on the Bass Highway, Tasmania on 1 April 2024. His white Toyota Hilux crossed the centre line into the path of an o…
Anthony Creaton, 55, died of acute myocardial infarction due to coronary artery thrombosis and atherosclerosis in prison custody. He presented with chest pain on 13 November 2022 (twice) and again on 14 November, but nur…
A 20-year-old learner motorcyclist died from traumatic injuries sustained in a collision with a power pole while accelerating aggressively on a public road. The rider was inexperienced (obtained learner permit 4 months p…
Jason Peter Wilson, aged 51, died from multiple injuries sustained in a single-vehicle motor crash on the Huon Highway, Tasmania. Toxicological analysis revealed elevated levels of methylamphetamine, MDMA, and cannabis i…
Sarah Anne Swallow, a 36-year-old woman with Down syndrome (Trisomy 21), died from peripheral T-cell lymphoma in September 2024. She was diagnosed with this aggressive cancer in April 2024 and commenced on chemotherapy, …
A 4-year-old girl drowned in a neighbouring pool after crawling through a gap in a shared boundary fence that served as a pool safety barrier. The fence had been certified as compliant in February 2024 but deteriorated s…
Dima Thomson, a 39-year-old man with a history of alcohol-fuelled domestic violence incidents and mental health conditions, died from multiple gunshot wounds after police attended his home responding to a breach of an ap…
Frances Jeyann Ramirez, a 22-year-old student, was fatally struck by two vehicles while crossing Hopkins Street in Footscray on 25 November 2023. She sustained multiple injuries and died at the scene. The coroner found t…
Duke Schafer, 36-year-old prisoner, was murdered by fellow inmate Carl Bloomfield in May 2020 at Woodford Correctional Centre. Bloomfield strangled Schafer in an unsupervised laundry area during a period when officers we…
A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…
Four young people died in a single-vehicle motor vehicle collision on 27 May 2023. Jorja Fox (16, learner driver) was driving Alicia Montebello's vehicle at excessive speed when she lost control on a rural road. The vehi…
Richard Ellis, a 64-year-old man with intellectual disability, schizophrenia, Parkinson's disease and oropharyngeal dysphagia, died from aspiration obstruction following a witnessed choking episode while eating. He prese…
A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…
A 39-year-old man drowned while snorkelling at Altona Beach wearing a 10.95 kg weight belt without fins or buoyancy compensation device. He became fatigued in deep, choppy water with poor visibility. The coroner found th…
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