A 44-year-old woman died from pulmonary thromboembolism 27 days after sustaining a Weber B ankle fracture from a fall. She was managed conservatively with a CAM boot then below-knee cast, with progressive immobilisation …
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …
David Stanley Bailey, aged 57, died on 17 August 2024 after being struck by a police vehicle driven by Sergeant Michael Preshaw on Flinders Island, Tasmania. Mr Bailey had consumed approximately 18 beers (approximately 5…
Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…
Giovanni John Miceli, a 53-year-old man with cerebral palsy and intellectual disability living in specialist disability accommodation, died from sepsis secondary to aspiration pneumonia. He had a known history of recurre…
Justin Filardo, aged 45, with a 28-year history of schizophrenia, was fatally shot by police after assaulting his sister Bianca in her bedroom. In the weeks prior, Justin had ceased his clozapine medication without clini…
Wayne Harris was a 56-year-old Aboriginal man with advanced metastatic sigmoid adenocarcinoma who died in prison custody from complications of his terminal cancer. He was incarcerated for 11 years for child sex offences.…
David Evan Wild, 61 years old, died of natural causes of unascertained origin while residing in specialist disability accommodation. He had frontal temporal dementia diagnosed in 2020 and required 24/7 care. He experienc…
A 40-year-old woman with Moebius syndrome, cerebral palsy and intellectual disability died from complications of influenza A infection. She resided in specialist disability accommodation with 24/7 support. On 3 July, she…
An 84-year-old man with Alzheimer's dementia and a history of wandering left his home on 15 September 2017 and was never found alive. The coroner determined he is deceased, likely died within days of going missing in bus…
A 30-year-old male motorcyclist died from head and neck injuries sustained in a motorcycle incident on the Western Ring Road on-ramp on 26 July 2018. The coroner found that a water leak from a fire hydrant on VicRoads-ow…
MK, 18 years old, died by drowning after his car entered Isabella Pond following a motor vehicle accident. Witnesses observed him inhaling from a balloon-shaped object while driving through a roundabout. A large nitrous …
Nelson Chan (47) and his son Joshua Chan (17) disappeared while rock fishing at Storm Bay, Kiama, NSW on 19 August 2024. Nelson's car was found parked near the fishing location, and Joshua's fishing rod and mobile phone …
Taewoo Kim, a 20-year-old South Korean working holidaymaker, died on 26 December 2024 after entering the ocean at the unpatrolled Moonee Beach, NSW. He was a poor swimmer, unfamiliar with the beach and ocean swimming, an…
Ronald Nieuwenhuis, a 65-year-old man with intellectual disability residing in supported accommodation, presented to hospital in January 2025 with abdominal pain and was found to have metastatic adenocarcinoma of gastroi…
A fatal head-on motor vehicle collision on the Capricorn Highway resulted in the deaths of four occupants of a Holden Commodore: the driver Shaun Michael Ranger (28), passenger Corey James Beitzel (32), and two children …
Jimmy Delcus, a 56-year-old man with autism, intellectual disability and schizoaffective disorder, died from aspiration of a food bolus while eating lunch in a park. He was receiving supported living services through Aru…
A 39-year-old man died by hanging on 16 February 2023 at his home in St Marys, NSW. His mother requested a police welfare check at 8:40pm after he posted a suicide note on Facebook at 2:30pm. Police attended twice (11pm …
Conner Stewart, 23-year-old male, died from head injuries sustained in a single-vehicle motor vehicle accident on 27 July 2022 at Burren Junction, NSW. A Toyota Landcruiser left the roadway on Bugilbone Road, rotated clo…
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