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VIC2022-05-17

Finding into death of Cameron Richard Plant

52y · Male·Hanging

Cameron Richard Plant, a 52-year-old male, died by hanging in hotel quarantine on 11 April 2020, shortly after returning to Australia from Dubai. He was experiencing significant psychosocial stressors including marriage …

psychiatrypublic healthcommunicationsystem
VIChospital2022-05-17

Finding into death of Mr J

36y · Male·Multiple Sharp Force Injuries to Chest and Neck

Mr J, a 36-year-old with a history of first-episode psychosis (2012) and relapse (2014) both associated with methamphetamine use, ceased antipsychotic medication in September 2019 with GP support after achieving 3 years …

general practicepsychiatrycommunicationdiagnosticpaliperidone
VIC2022-05-10

Finding into death of Choon Jie Chai

18y · Male·Drowning

An 18-year-old Malaysian visitor drowned in a hotel swimming pool after entering water despite being unable to swim. He was attempting to rescue a colleague who had also gotten into difficulty. The pool was unattended by…

systemcommunicationmidazolam
VIChospital2022-05-09

Finding into death of Robert Albert Burns

75y · Male·Multiorgan dysfunction syndrome complicating anastomotic leak following hemicole…

A 75-year-old man died from multiorgan dysfunction following an anastomotic leak after hemicolectomy for caecal adenocarcinoma. Initial post-operative recovery appeared normal, but he deteriorated from day 3 onwards. The…

colorectal surgeryintensive carediagnosticdelay
VIChospital2022-05-06

Finding into death of Trevor Anthony Peterson

57y · Male·Sepsis from ischemic bowel due to superior mesenteric artery thrombus

Trevor Peterson, a 57-year-old with chronic gut ischemia, underwent mesenteric artery stenting in February 2020. Discharge instructions emphasising dual antiplatelet therapy (DAPT) were not clearly communicated to the va…

vascular surgeryradiologycommunicationsystemaspirin
NSWmental health2022-05-06

Inquest into the death of Diane EASTCOTT

71y · Female·ischaemic cardiovascular disease

Diane Eastcott, a 71-year-old involuntary mental health patient, died of ischaemic cardiovascular disease on 10 July 2018 at Macquarie Hospital. Following an unwitnessed fall on 22 June 2018, she was admitted to Ryde Hos…

emergency medicinecardiologymedicationcommunicationmetoprolol
VIChospital2022-05-05

Finding into death of PX O

49y · Male·Complications of a right superficial femoral artery injury (operated) following …

A 49-year-old man died from complications of a right superficial femoral artery injury sustained when he was struck by a circular saw at a landscaping worksite. Despite receiving immediate first aid, emergency transport …

trauma surgeryvascular surgerysystemcommunication
VIChospital2022-05-04

Finding into death of Marlene Sako

25y · Female·self-immolation

Marlene Sako, a 25-year-old woman struggling with alcohol dependence following a traumatic marriage breakdown, presented to Northern Hospital on 29 November 2015 with threats of self-harm and suicide attempts. Despite a …

emergency medicinepsychiatrydiagnosticcommunicationalcohol
VICmental health2022-05-02

Finding into death of Stuart Brant Garten

34y · Male·Hypoxic/ischaemic brain injury following resuscitated cardiac arrest and hanging

Stuart Brant Garten, a 34-year-old man with complex psychiatric diagnoses including borderline personality disorder, post-traumatic stress disorder, and schizophrenia, died by hanging in the courtyard of a secure extende…

psychiatryintensive carecommunicationsystemrisperidone
TAS2022-04-29

Coroner's Finding: Lavoipierre, Andre Marc

41y · Male·exsanguination (hypovolemic shock complicating acute blood loss) due to fistula …

Andre Marc Lavoipierre, age 41, died on 26 June 2019 from exsanguination due to internal bleeding (ureter-iliac artery fistula or steady renal/bladder bleed). He fell at his supported residential unit on the morning of d…

psychiatrygeneral practicecommunicationdelayfluoxetine
QLDcommunity2022-04-28

Mathieson, Troy James and Morton, Hughie Kirk Douglas

23y · Male·Drowning/immersion

Troy Mathieson (23) and Hughie Morton (21) drowned in flood waters while entering a culvert to avoid police detention during extreme flooding in Townsville on 4 February 2019. The men entered a flooded drain after being …

delaycommunicationalcohol
VIChome2022-04-27

Finding into death of Leonardo Antonio Biancofiore

61y · Male·Neck injuries in the setting of a dog attack

Leonardo Biancofiore, 61 years old with longstanding syringomyelia requiring mobility aids, died from massive neck injuries sustained in a dog attack by his American Staffordshire Terrier at his home. The attack occurred…

emergency medicineforensic medicinesystemcommunication
QLDhospital2022-04-26

Jessen, Tyson Lee

28y · Male·Gunshot wounds of the neck, chest and abdomen

Tyson Jessen, a 28-year-old man wanted for armed robbery in Victoria, was arrested in Queensland and admitted to Ipswich Hospital with cardiac symptoms. While in police custody, he remained under guard in hospital. Senio…

emergency medicinecardiologycommunicationsystemmetoprolol
SAcommunity2022-04-22

Coroner's Finding: Bentley, John James

80y · Male·Dehydration and the effects of heat with contributing Alzheimer's dementia

An 80-year-old man with advanced Alzheimer's dementia disappeared from a respite care facility on a day of extreme heat (39°C) and died from dehydration and heat exposure. Key failures included: (1) relocation of the day…

geriatric medicineemergency medicinediagnosticsystem
SAhome2022-04-21

Coroner's Finding: Rigney, Amber Rose and Mitchell, Korey Lee

Unknown·Amber Rose Rigney: external airway occlusion with compression of the neck; Korey…

Two children, Amber Rose Rigney (6) and Korey Lee Mitchell (5), were murdered on 30 May 2016 by their mother's partner Steven Graham Peet. The Coroner found their deaths were preventable. The children's mother had been u…

paediatricssystemdelayice/methamphetamine
VIC2022-04-20

Finding into death of John Kennard

39y · Male·Injuries sustained in a fall from a height

John Kennard, aged 39, died from injuries sustained falling from a fourth-floor balcony while attempting to escape police executing a bench warrant for his arrest. Police officers allowed him to return to his apartment u…

proceduralcommunicationmethadone
WAcommunity2022-04-13

Inquest into the Death of Ms B (Name Subject to Suppression Order)

40y · Female·effects of fire including smoke inhalation, thermal injuries and incineration

Ms B, aged 40, died when a stolen Ferrari she was a passenger in collided with a steel barrier and caught fire following a police pursuit incident on 25 May 2019 in North Perth, WA. The driver (an offender) fled from pol…

forensic medicinecommunicationproceduralmethamphetamine
WAhome2022-04-13

Inquest into the Death of Boris DRLESKI

45y · Male·bronchopneumonia and combined drug toxicity

Boris Drleski, a 45-year-old with treatment-resistant chronic paranoid schizophrenia, antisocial personality disorder, and polysubstance use disorder, died from bronchopneumonia and combined drug toxicity. He was managed…

psychiatryemergency medicinecommunicationsystemzuclopenthixol decanoate
SAhospital2022-04-13

Coroner's Finding: Cook, Courtney Liza

20y · Female·multi-organ failure due to polypharmacy overdose

A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where i…

emergency medicinegastroenterologydiagnosticcommunicationparacetamol
NSWhome2022-04-13

Inquest into the death of Tateolena TAUAIFAGA

1y · Female·Blunt head injuries

Tateolena Tauaifaga, a 17-month-old child, died from blunt head injuries when a stolen vehicle pursued by police during a high-risk vehicle intercept (HRVI) crashed through her home's fence into her backyard. Critical fa…

systemcommunication

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