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VIChospital2014-12-16

Finding into death of Michael Justin Nicoll

36y · Male·Multiorgan failure complicating Streptococcus pyogenes septicaemia

Michael Nicoll, 36, presented to Cabrini Hospital ED with diarrhoea, vomiting, and dehydration. Dr P. diagnosed gastroenteritis and discharged him after IV fluids, despite dehydration, tachycardia, elevated creatinine, a…

emergency medicineintensive carediagnosticsystemondansetron
VICcommunity2014-12-08

Finding into death of Craig Douglas

31y · Male·Gunshot wounds to chest

Craig Douglas died from gunshot wounds sustained during a police encounter in St Kilda on 2 May 2011. Following an armed robbery at a hotel involving Douglas and others, two constables (Cross and O'Donnell) engaged the s…

communicationproceduralmethadone
QLDhome2014-11-26

Smith, Rachel Danielle - Non-inquest findings

25y · Female·mixed drug toxicity

Rachel Smith, a 25-year-old woman with chronic migraines and depression, died from mixed drug toxicity after consuming multiple prescription medications including oxycodone, codeine, tramadol, diazepam, amitriptyline and…

general practiceneurologydiagnosticsystemoxycodone
VICmental health2014-11-17

Finding into death of Justin Peter Foster

40y · Male·unascertained

Justin Foster, a 40-year-old man with bipolar affective disorder, chronic back pain, and substance abuse history, died suddenly in a psychiatric inpatient unit (Upton House) on 3 January 2012. He was admitted involuntari…

psychiatryforensic medicinecommunicationdiazepam
VIChome2014-10-30

Finding into death of Anne Christine Brain

44y · Female·Intoxication by the combined effects of tramadol, methadone, diazepam, codeine, …

Anne Christine Brain, a 44-year-old woman with schizophrenia, anxiety, and depression who was opioid-dependent, died from intoxication by combined effects of tramadol, methadone, diazepam, codeine, alprazolam, risperidon…

general practiceaddiction medicinesystemcommunicationtramadol
VICmental health2014-10-07

Finding into death of Warren Guneratne

25y · Male·consistent with drowning in a man with multiple injuries

Warren Guneratne, a 25-year-old man with paranoid schizophrenia, was admitted involuntarily to the psychiatric unit of Royal Melbourne Hospital on 28 January 2008 after assessment by the Crisis Assessment and Treatment T…

psychiatryemergency medicinecommunicationsystemclozapine
VIC2014-10-07

Finding into death of Darren Carr Hannah

41y · Male·Upper airway obstruction from ingestion of dirt in an intellectually impaired ma…

Darren Hannah, a 41-year-old man with severe intellectual disability, autism, partial blindness and longstanding pica disorder, died from upper airway obstruction after ingesting large quantities of dirt in the backyard …

general practicepsychiatrysystemsupervisiondiazepam
VIChome2014-10-06

Finding into death of Peter Andrew McNay

50y · Male·hanging

50-year-old male with long-standing substance abuse history (alcohol, marijuana, heroin until 2009) and complex mental health issues including depression, anxiety, personality traits, and multiple prior suicide attempts.…

psychiatryaddiction medicinealcohol
VIChospital2014-09-30

Finding into death of Robert James Barron

64y · Male·lung cancer

Robert James Barron, aged 64, was a psychiatric inpatient at Thomas Embling Hospital, involuntarily detained under the Mental Health Act since 2000 and subject to parole supervision. In December 2012, his physical health…

psychiatrygeneral medicineclozapine
VIC2014-09-11

Finding into death of Lloyd Felman

58y · Male·Amitriptyline toxicity

Lloyd Felman, a 58-year-old man with chronic pain, depression, and alcohol use, died from amitriptyline toxicity in July 2008. In the three weeks prior, he presented to hospital three times with bizarre high-risk behavio…

psychiatryemergency medicineamitriptyline
NTcommunity2014-09-01

Inquest into the death of Braydon Brown

17y · Male·bacterial meningitis

A 17-year-old Aboriginal student died from bacterial meningitis after three clinic presentations in Yuendumu over four days. The critical failure occurred on 1 April when fever (38.3°C), persistent headache, and positive…

general practiceemergency medicinediagnosticcommunicationdiazepam
VICcommunity2014-09-01

Finding into death of Kirstan McRae-Jansen

31y · Female·plastic bag asphyxia

Kirstan McRae-Jansen, a 31-year-old woman with chronic schizophrenia, borderline personality disorder, and substance abuse, died by plastic bag asphyxia using an LPG bottle. She was under Community Treatment Order with E…

psychiatryolanzapine
VICmental health2014-08-04

Finding into death of Frederick Joseph Williamson

52y · Male·consistent with plastic bag asphyxia

Frederick Williamson, a 52-year-old man with chronic treatment-refractory schizophrenia, was found dead in the bathroom of his room at Austin Health's Secure Extended Care Unit with a plastic bag over his head, consisten…

psychiatryforensic medicinediagnosticsystemquetiapine
VIChospital2014-07-28

Finding into death of Glen David Kingsun

42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…

Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…

general practiceemergency medicinemedicationcommunicationverapamil
QLDhome2014-07-25

Petersen, Nicole - Non-inquest findings

19y · Female·Mixed drug toxicity, with morphine (from poppy seeds) and dextromethorphan (from…

Nicole Petersen, aged 19, died from mixed drug toxicity due to consumption of poppy seed tea combined with cough syrup and diazepam. She became unresponsive overnight and was discovered in cardiac arrest around 5:45am. H…

emergency medicinetoxicologydelaysystemmorphine
NT2014-07-21

Inquest into the death of Ryan Smiler

39y · Male·cardiac arrest caused by alcoholic cardiomyopathy

Ryan Smiler was a 39-year-old Aboriginal man who died from cardiac arrest caused by alcoholic cardiomyopathy while in custody at Darwin Correctional Centre. He had a long history of alcohol abuse, hypertension, and heart…

cardiologyemergency medicinedelaywarfarin
VIC2014-07-04

Finding into death of Samir Ograzden

25y · Male·Gunshot injury to the neck

A 25-year-old man was shot and killed during a police pursuit in May 2008 after fleeing a vehicle stop where drugs and a firearm were found. He was pursued on foot through Melbourne streets, entered a car park, fired at …

emergency medicineforensic medicineamphetamine
VICcommunity2014-06-30

Finding into death of Lewis John Muratori

50y · Male·Multiple injuries as a result of being struck by a train

A 50-year-old ICU nurse at Cabrini Hospital died by suicide by stepping in front of a train after experiencing a cascade of adverse events. In October 2009, he attended work while intoxicated following personal stress, l…

psychiatryemergency medicinecommunicationsystemaurorix
NSWcommunity2014-06-27

Inquest into the deaths of Christopher SALIB, Nathan ATTARD and Shamsad AKHTAR

Christopher Salib: ischaemic heart disease with multiple prescription drug toxic…

This landmark inquest examined three deaths involving prescription drug toxicity: Christopher Salib (24, ischaemic heart disease with drug toxicity), Nathan Attard (34, multi-drug toxicity), and Shamsad Akhtar (35, multi…

general practiceemergency medicinediagnosticmedicationalprazolam
VIChome2014-06-19

Finding into death of William John Bailey

22y · Male·Combined drug toxicity (methadone and benzodiazepines)

William John Bailey, a 22-year-old man recently released from prison, died from combined drug toxicity involving methadone and benzodiazepines. He consumed methadone takeaway doses prescribed to his housemate Ms Rattya w…

addiction medicineemergency medicinesystemmethadone
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