Coronial
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VIC2016-09-01

Finding into death of Jarrod Joseph Debono

21y · Male·Electrocution

A 21-year-old apprentice electrician died from electrocution while troubleshooting LED lighting installation work in a residential roof cavity. He was attempting to repair lights by stripping a broken neutral conductor w…

proceduralamiodarone
VIChospital2016-08-31

Finding into death of Nathan Dimech

17y · Male·Global cerebral ischaemic injury and aspiration pneumonia post cardiac arrest du…

Nathan Dimech, a 17-year-old with intellectual disability and substance abuse issues, died from methadone toxicity after consuming his father's opioid replacement therapy (ORT) dose from a refrigerator. Nathan's father, …

general practicepharmacycommunicationsystemmethadone
VIChospital2016-08-19

Finding into death of Margaret Smith

91y · Female·Unascertained

Margaret Smith, a 91-year-old admitted with head strike from fall, developed moderate depression during her stay and received electroconvulsive therapy (ECT) as a compulsory patient. On 5 March 2015, she developed epigas…

psychiatrygeriatric medicinediagnosticdelaylithium
VIChospital2016-06-09

Finding into death of James Sawbridgeworth

86y · Male·Multisystem failure complicating injuries sustained in a motor vehicle collision…

An 86-year-old man with cardiac history died from multisystem failure following a pedestrian motor vehicle collision. He was struck by a prime mover while crossing against traffic, sustaining a broken leg, pelvis fractur…

trauma surgeryintensive carefentanyl
VIChospital2015-11-30

Finding into death of Maria Dolores Coliero

69y · Female·Inadvertent intravenous administration of oral ciprofloxacin in the setting of a…

A 69-year-old woman with stroke, diabetes, atrial fibrillation and osteomyelitis died from inadvertent intravenous administration of crushed oral ciprofloxacin. The antibiotic was prescribed for the nasogastric tube but …

intensive careinfectious diseasesmedicationproceduralciprofloxacin
VICcommunity2014-08-25

Finding into death of William Patrick Slater

67y · Male·Multiple injuries from motor vehicle collision

William Patrick Slater, aged 67, was killed in a motor vehicle collision caused by Kane Miller, a 24-year-old driver with schizophrenia who was on prescribed medication and had tested positive for morphine, cannabis, mid…

forensic medicinepsychiatrysystemdelaymorphine
WAhospital2013-09-24

Inquest into the Death of Whiteford, Carol Freda

68y · Female·Anaphylaxis in a woman with atherosclerotic cardiovascular disease and emphysema

A 68-year-old woman with severe COPD and undiagnosed atherosclerotic heart disease underwent cataract surgery at Northam Hospital. Post-operatively, she was prescribed Diamox (acetazolamide), a sulphonamide medication. D…

ophthalmologyanaesthesiadiagnosticmedicationdiamox
VIChospital2013-09-10

Finding into death of Paul Gary Larman

28y · Male·Overdose of Clozapine

A 28-year-old man with schizophrenia and substance abuse history died from clozapine overdose. Key clinical failures included: inadequate assessment of suicide risk when prescribing one month's supply to a patient presen…

psychiatryemergency medicinediagnosticmedicationclozapine
WAhome2013-09-05

Inquest into the Death of Doherty, Craig James

39y · Male·propofol toxicity

Craig Doherty, a 39-year-old clinical theatre nurse at Royal Perth Hospital, died from propofol toxicity in June 2010. He had unrestricted access to propofol as an anaesthetic agent and misappropriated it for recreationa…

anaesthesiapharmacysystemdelaypropofol
QLDhospital2012-11-28

Hammett, Christopher

47y · Male·Aspiration pneumonia due to or as a consequence of coronary atherosclerosis

Christopher Hammett, a fit 47-year-old, died from aspiration pneumonia with contributing coronary atherosclerosis following routine L5-S1 disc replacement. A critical oxygen desaturation (64%) occurred during transfer fr…

orthopaedic surgeryanaesthesiadiagnosticcommunicationmorphine
SAcommunity2012-11-15

Coroner's Finding: Edgar Lauren Michelle

28y · Female·Multi-organ failure due to Clostridium perfringens myonecrosis complicating lipo…

Lauren Edgar, a 28-year-old woman, died of multi-organ failure from Clostridium perfringens myonecrosis (gas gangrene) following a liposuction procedure performed by Dr K. on 5 March 2008. She presented to hospital on 8 …

plastic and reconstructive surgerygeneral practicediagnosticcommunicationpanadol/paracetamol
NSWhospital2011-08-12

Godden,george 2011 08 31 14 50 44 877

Unknown·Lignocaine toxicity following dental surgery with atherosclerotic and valvular h…

George Godden died at Prince of Wales Hospital on 22 February 2007 from lignocaine toxicity following dental surgery. His post-extraction gingival bleeding was treated with gauze soaked in co-phenylcaine spray, a medicat…

dentistrygeneral medicinemedicationprocedurallidocaine
VIChospital2010

Finding into death of Nicole Joy Millar

42y · Female·Complications of cutaneous burns

Nicole Joy Millar, 42, died from severe burns inflicted by her intimate partner in a premeditated attack at a petrol station. She had disclosed prior intimate partner violence to support services but remained isolated an…

emergency medicineplastic and reconstructive surgerycommunicationsystemdiazepam
SAhospital2008-05-23

Coroner's Finding: KROL Riley

0y · Male·hypoxic ischaemic encephalopathy

Riley Krol, a 11-day-old male infant, died from hypoxic ischaemic encephalopathy following emergency caesarean section delivery on 1 March 2005. After artificial rupture of membranes during labour induction, the foetus d…

obstetricsanaesthesiacommunicationsystemcervedil
SAhospital2006-11-13

Coroner's Finding: SALMON Daniel Brindley

27y · Male·Airway obstruction due to sublingual and submandibular cellulitis (Ludwig's angi…

A 27-year-old man died from airway obstruction due to Ludwig's angina (bilateral sublingual and submandibular cellulitis) following a tooth extraction. Critical failures included: delayed treatment with inadequate timely…

emergency medicinedentistrycommunicationdiagnosticparacetamol/codeine
QLDhospital2006-08-10

Casey, Lenard John

39y · Male·Coronary thrombosis caused by coronary atherosclerosis

Lenard Casey, a 39-year-old Aboriginal man with severe coronary artery disease, died of acute coronary thrombosis while in custody. Arrested for assault on his partner, he developed chest pain at the police station and w…

cardiologyemergency medicinecommunicationmorphine
SAhospital2005-05-24

Coroner's Finding: WALLACE-MOHLMANN Candice Mackenzie

30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…

Candice Mackenzie Wallace-Mohlmann, a 30-year-old woman with chronic schizophrenia and substance abuse history, died from hypoxic brain injury caused by self-injection of vecuronium and atropine obtained from a hospital …

psychiatryemergency medicinediagnosticmedicationvecuronium
SAcommunity2004-07-16

Coroner's Finding: DINSDALE Cheree Ann and KLINGNER Peter James

20y · Unknown·Traumatic brain damage complicating gunshot wound to the head

Two young adults aged 20 died from gunshot wounds to the head on 29-30 May 2001 in what appears to be a murder-suicide involving Peter Klingner and his girlfriend Cheree Dinsdale. Klingner had paranoid schizophrenia with…

psychiatryemergency medicinediagnosticcommunicationolanzapine
NTcommunity2003-09-05

Inquest into the death of Mark Corbett

48y · Male·Acute cardiac dysrhythmia of unknown cause; acute alcohol toxicity was a signifi…

Mark Corbett, a 48-year-old Aboriginal man, died from acute cardiac dysrhythmia while in police protective custody in Tennant Creek. He was apprehended twice for public intoxication on 10 July 2002. After leaving a sober…

emergency medicineanaesthesiacommunicationsystemalcohol
WAhospital2003-08

Inquest into the Death of Richard Christopher Jankowski

39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…

Richard Christopher Jankowski, a 39-year-old man, died from hypoxic brain injury due to respiratory obstruction following emergency surgery for a dental abscess with cellulitis. After initial treatment with antibiotics, …

anaesthesiageneral surgeryproceduralcommunicationpropofol

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