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VICcommunity2022-04-04

Finding into death of Andrew Francis Powell

32y · Male·Drowning

Andrew Powell, a 32-year-old volunteer lifesaver, drowned on 21 April 2019 while performing a rescue operation in rough seas at Port Campbell, Victoria. A tourist became trapped in strong currents at Sherbrook Beach. The…

communicationsystem
VIC2022-04-04

Finding into death of Ross William Powell

71y · Male·Drowning

Ross Powell, a 71-year-old experienced volunteer lifesaver, died by drowning on 21 April 2019 while operating the Pelican rescue vessel during a maritime emergency at Port Campbell, Victoria. A tourist (Mr Bhaskar) had e…

emergency medicinesystemcommunication
WAcommunity2022-04-01

Inquest into the Death of Cherdeena Shaye WYNNE

26y · Female·hypoxic ischaemic encephalopathy and bronchopneumonia in a woman with methylamph…

Ms Cherdeena Wynne, a 26-year-old Noongar Yamatji woman, died from hypoxic ischaemic encephalopathy and bronchopneumonia following cardiac arrest during police restraint on Albany Highway. She was intoxicated with methyl…

psychiatryemergency medicineproceduralcommunicationmethamphetamine
VIChome2022-03-31

Finding into death of Maria James

38y · Female·haemorrhage from stab wounds

Maria James was murdered in her home bookshop in Thornbury on 17 June 1980, stabbed 68 times. The killer has never been identified. This coronial inquest examined the adequacy of the original police investigation and ide…

forensic medicinesystemdelay
VIChome2022-03-31

Finding into death of Tessa Michelle Ballam

31y · Female·neck compression in the circumstances of hanging

Tessa Ballam, a 31-year-old accountant with longstanding depression, anxiety, bulimia nervosa, and borderline personality disorder (BPD), died by hanging in August 2015. She had experienced workplace difficulties with he…

psychiatrypsychologycommunicationsystemalcohol
VICprison2022-03-30

Finding into death of Charles Bertram Squires

76y · Male·Intracranial haemorrhage

Charles Bertram Squires, a 76-year-old prisoner on anticoagulant therapy (apixaban and aspirin), fell and struck his head on 26 January 2017. Nursing staff at the correctional facility inadequately assessed his traumatic…

emergency medicineneurosurgerydiagnosticcommunicationapixaban
VICmental health2022-03-30

Finding into death of B J

24y · Male·Hypoxic brain injury secondary to hanging

BJ, a 24-year-old with paranoid schizophrenia, substance abuse disorder, and anti-social personality disorder, died by hanging in a psychiatric unit after a suicide attempt. He was admitted on 4 January 2016 with suicida…

psychiatryemergency medicinecommunicationsystemquetiapine
NSWhome2022-03-30

Inquest into the deaths of Stacey DOCHERTY and Seth DOCHERTY

38 and 3y · Female and male·Stacey: hanging; Seth: undetermined causes (likely suffocation, drowning, or str…

Stacey Docherty, a 38-year-old woman with complex post-traumatic stress disorder and borderline personality disorder resulting from childhood sexual abuse, killed her 3-year-old son Seth before taking her own life in Mar…

psychiatrygeneral practicemedicationcommunicationalprazolam
VIC2022-03-28

Finding into death of Deva Rebecca Frijlink

42y · Female·Choking on a food bolus

Deva Frijlink, aged 42 years with intellectual disability and schizoaffective disorder, died from choking on a food bolus during a supervised mealtime excursion. She was under the care of a support worker at a shared acc…

speech pathologyemergency medicinecommunicationsystemdiazepam
WAhospital2022-03-28

Inquest into the Death of Morgan John EDWARDS

31y · Male·Complications in association with intestinal volvulus

31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…

emergency medicinegastroenterologydiagnosticcommunication
VIChome2022-03-25

Finding into death of Ms WJ

59y · Female·Sepsis in a woman with epilepsy, cerebral palsy and haemochromatosis

A 59-year-old woman with cerebral palsy, epilepsy, and intellectual disability died of sepsis from a urinary tract infection (urosepsis) caused by E. coli and Proteus mirabilis. She had four hospital presentations in the…

emergency medicinegeneral medicinecommunicationsystemmetoclopramide
NSWhospital2022-03-25

Inquest into the death of Anthony Barrett

54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…

Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…

orthopaedic surgeryvascular surgerycommunicationdiagnosticclopidogrel
VIC2022-03-24

Finding into death of Ivica Andrijasevic

54y · Male·neck compression

Ivica Andrijasevic, a 54-year-old boilermaker, died from neck compression after being crushed by a malfunctioning Mobile Elevated Work Platform (MEWP) at a construction site. The MEWP's jib switch was defective and faile…

systemprocedural
VICcommunity2022-03-16

Finding into death of John Anthony Kamps

62y · Male·Hypoxic ischaemic encephalopathy complicating acute upper airway obstruction by …

John Kamps, a 62-year-old man with intellectual disability, autism, epilepsy, and dysphagia, died from hypoxic ischaemic encephalopathy following airway obstruction by food bolus. He choked on toast at breakfast despite …

speech pathologyemergency medicinesystemcommunication
TAScommunity2022-03-14

Coroner's Finding: PL

7y · Male·head injuries from ejection onto rocky riverbank during boating accident

A 7-year-old boy died from catastrophic head injuries after being ejected from a ski biscuit during a recreational boating accident on the Prosser River in Tasmania. The vessel operator was towing the child at excessive …

emergency medicineintensive careproceduralcommunication
NSWhospital2022-03-11

Inquest into the death of Kelvin Forrest

53y · Male·multiple injuries sustained in a fall from the first floor

Kelvin Forrest, a 53-year-old man with Down syndrome and dementia, died from multiple injuries sustained in a fall from the first floor of Byron Central Hospital on 28 July 2018. He had been admitted as a medical patient…

general medicinegeriatric medicinediagnosticcommunication
VIC2022-03-10

Finding into death of Joanne Callahan

43y · Female·choking on a food bolus

Joanne Callahan, a 43-year-old woman with intellectual disability and autism, died from choking on a food bolus while attending a disability day program. Critical failures in communication between her residential care pr…

speech pathologyparamedicinecommunicationsystem
VIChome2022-03-10

Finding into death of PFS

50y · Female·Hanging

A 50-year-old woman died by hanging in December 2017 after a relationship characterised by family violence and her own depression. She had been in an intimate partner violence situation for years, had presented to ED wit…

psychiatrypsychologycommunicationsystemsertraline
VICaged care2022-03-09

Finding into death of Erica Hubai

51y · Female·Aspiration pneumonia

A 51-year-old woman with Sturge-Webber syndrome and poor swallowing ability presented to hospital with a cough and was admitted on 15 December 2017, following a choking incident at her group home. She died on 23 December…

general practicerespiratory medicinecommunicationsystem
VIChome2022-03-08

Finding into death of David Charles Shaw

57y · Male·Ischaemic and valvular heart disease

David Charles Shaw, 57, died of ischaemic and valvular heart disease with severe coronary artery atherosclerosis. He was enrolled in MePACS, a medical alarm service requiring daily button activation between 6-11am. When …

general practicecardiologysystemdelay

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