07:00am Lindsey went to work. His colleagues reported that he was his usual self.

07:00am Lindsey got up to go to work, but was still not feeling well. He took two Codral day-time cold and flu tablets, before walking out to his car. A few minutes later, he returned to the house stating “he was too sick to go to work”, and to “call my boss”.

07:40am The ambulance arrived, and the paramedics worked on Lindsey for approximately 20 minutes before transporting him to Nepean Hospital by ambulance in ventricular fibrillation (VF) cardiac arrest.

04:22pm A clinical examination found absence of brain stem reflexes, and declaration of brain death was made by the treating team.  As Lindsey was an organ donor, suitable organs were removed.

• An autopsy report for the coroner was issued.
• In the opinion of the forensic pathologist who conducted the autopsy, the cause of death was Acute Respiratory Distress Syndrome (ARDS), with no antecedent causes.
• The autopsy report included the following comment: “Acute respiratory distress syndrome can be idiopathic, or caused by acute interstitial pneumonia, infection, drugs, autoimmune diseases, inhalation injuries, sepsis, radiation therapy and burns, among other causes. Acute interstitial pneumonia is a fulminant lung disease in previously healthy individuals and usually has an unknown cause. lnterstitial pneumonia can be a rare complication of the influenza vaccine and 9 cases have been described since 1998 with the age range (more men than women) between 38 and 75 years. The interval between vaccination and onset of symptoms was 1-7 days and the interval between vaccination and diagnosis was 2-41 days. (lnterstitial Pneumonia Associated with the influenza Vaccine: A Report of Two Cases: Makoto Hibina and Tetsuri Konda, lntern Med 56: 197-201, 2017 DOI: 10.2169/internalmedicine.56.7239).”

• NSW Health convened an expert review panel after they “became aware of a report of a 39 year old male who had died on 2 May 2018 with history of a FluQuadri vaccine dose given on 29 April 2018”.
• The expert panel did not include a Neurology expert, and did not consider the fact Lindsey had received a Boostrix vaccine, in addition to a FluQuadri vaccine.

• A report was issued by the NSW Health Expert Review Panel which concluded that Lindsey died from a cardiac event.
• The report noted that “out-of-session advice on the case was provided by a cardiology specialist who also agreed with the Expert Panel’s findings the likely cause of death was cardiac in origin”.

I was advised by the Acting Registrar of the State Coroner’s Court, that, based on the new evidence from the NSW Health Expert Review Panel, “the Coroner is likely to amend the cause of death to “Coronary Artery Disease”, with ARDS noted as a significant condition”.

I was advised by the Acting Registrar of the State Coroner’s Court that “the Coroner has now had a chance to review the issues and concerns you raise” and is of the view that “given your significant concerns, it is appropriate to re-open this matter and to hold an inquest where all the medical evidence can be carefully and fully examined in open court”.

A supplementary report to the coroner by the forensic pathologist who conducted the autopsy noted the presence of both “old and acute ischaemic changes in the heart” which is inconsistent with the original autopsy findings of only “acute ischaemic changes in the heart”, “in the range aged between 12 to 24 hours”.