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QLDPodcast2022-01-25

Ofner, Johann

28y · Male·Gunshot wound to the chest causing cardiovascular collapse due to laceration, hy…

Johann Ofner, a professional stunt performer, died on 23 January 2017 after being shot with a shotgun during filming of a music video in Brisbane. He was believed to be using blank-fire ammunition; however, theatrical ar…

systemcommunicationopioid medication
NSW2022-01-25

Inquest into the death of Nick NEWMAN

33y · Male·Multiple gunshot wounds

Nick Newman, 33, died from multiple gunshot wounds during execution of an arrest warrant for serious child sexual assault offences. Police conducted inadequate risk assessment despite accessible intelligence indicating h…

diagnosticcommunication
WAhospital2022-01-25

Inquest into the Death of Carole LIVESEY

54y · Female·unascertained

Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…

psychiatrygeneral medicinecommunicationproceduralfluoxetine
VICcommunity2022-01-20

Finding into death of YLM

78y · Male·Ruptured abdominal aortic aneurysm

A 78-year-old man died from rupture of a previously undiagnosed 7.1cm abdominal aortic aneurysm. A CT scan ordered for suspected renal colic incidentally discovered the aneurysm and recommended vascular review. The GP ap…

general practiceradiologycommunicationsystem
VIChospital2022-01-20

Finding into death of Ann-Maree Manno

57y · Female·Pulmonary thromboembolism

Ann-Maree Manno, 57, died from pulmonary thromboembolism 8 days after laparoscopic gastric band surgery. She had significant risk factors: obesity (BMI 37.9), history of unprovoked DVT in 2007 and 2016, and recent surger…

bariatric surgeryanaesthesiacommunicationsystemheparin
QLDhome2022-01-18

Lewis, Daniel Patrick

36y · Male·Gunshot wounds to the chest and abdomen

Daniel Lewis, aged 36, died from gunshot wounds after police responded to a domestic violence call. Lewis had a history of brain injury from age 11, substance abuse, mental health issues including PTSD and drug-induced p…

psychiatryemergency medicinecommunicationsystemalcohol
WAhospital2022-01-17

Inquest into the Death of Peter Johnnie YOUNG

Male·Complications of alcohol and hepatitis C-related liver disease

Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…

hepatologygastroenterologysystemdelayquetiapine
WAhome2022-01-17

Inquest into the Death of Shaun Andrew WILLIS

54y · Male·Ligature compression of the neck (hanging)

Shaun Willis, aged 54, died by hanging at his home on 8 March 2019 following a turbulent separation and family violence history. He was arrested on 7 March for assaulted his ex-wife and served with a Family Violence Rest…

communicationsystemalcohol
VIChome2022-01-12

Finding into death of Linda-Jane Margaret Tatterson

40y · Female·combined drug toxicity (clomipramine, sertraline, diazepam, and quetiapine)

Linda-Jane Tatterson, aged 40, died from combined drug toxicity involving clomipramine, sertraline, diazepam, and quetiapine. She had a longstanding history of depression, OCD, and recurrent overdoses between 2014-2016. …

general practicepsychiatrycommunicationsystemclomipramine
QLDcommunity2022-01-11

Noombah

39y · Male·Cardiac arrest in a person with pre-existing severe ischaemic heart disease who …

A 39-year-old First Nations man with severe ischaemic heart disease died following police restraint and ambulance care during an emergency examination authority detention. He had sniffed petrol and threatened self-harm; …

emergency medicineparamedicinediagnosticcommunicationpetrol
VIChospital2022-01-10

Finding into death of John Wilfred Warner

79y · Male·Complications of multiple injuries (operated), sustained in a motor vehicle inci…

A 79-year-old man died from complications of multiple injuries sustained when his wife's vehicle was struck by an unmarked police car at an intersection. The police vehicle was engaged in a pursuit of a stolen vehicle an…

proceduralcommunication
VIChome2022-01-10

Finding into death of Deborah Marie Holtkamp

52y · Female·Mixed drug toxicity

Deborah Marie Holtkamp, 52, died from mixed drug toxicity in July 2018 in circumstances consistent with suicide. She had a long history of depression, childhood abuse trauma, chronic pain conditions, and recent relations…

general practicepsychiatrydiagnosticcommunicationmorphine
TAScommunity2022-01-05

Coroner's Finding: Forrest, Allan Leslie

66y · Male·blunt trauma head and chest

A 66-year-old man with advanced heart and lung disease attended hospital with calf pain investigated for DVT post-COVID vaccination. He was given anticoagulation and discharged. Despite appearing unwell and unsteady to h…

general practiceemergency medicinediagnosticcommunicationanticoagulation medications
VIChome2022-01-03

Finding into death of Patricia Jocelyn Eve Grant

83y · Female·Aspiration bronchopneumonia in a setting of cerebral infarction

Ms Patricia Grant, 83, died from aspiration bronchopneumonia following cerebral infarction while living with her son and daughter-in-law. She experienced severe neglect and elder abuse in her final years: cessation of ep…

general practicegeriatric medicinediagnosticsystem
VICmental health2022

Finding into death of LKV LKV

73y · Male·Neck compression in the circumstances of hanging

A 73-year-old man with severe depression and suicidal ideation died by hanging at a private psychiatric facility on 9 February 2019 during voluntary admission. He was assessed as low risk despite recent suicidal statemen…

psychiatrygeneral practicediagnosticsystemescitalopram
VIChospital2022

Finding into death of Mr E

67y · Male·Fulminant liver failure

A 67-year-old man presented to his GP with discoloured urine. Blood tests revealed acute liver toxicity but critical results were communicated via facsimile, with unclear timing of GP's review. The patient deteriorated r…

general practiceemergency medicinecommunicationdelayibuprofen
VIChome2022

Finding into death of Baby A

0y · Male·Pneumonia in the setting of malnutrition

Baby A, born at home without medical assistance, died at 19 days old from pneumonia complicated by severe malnutrition and dehydration. He weighed 2.87kg at autopsy, far below his reported 4kg birth weight. He had diffic…

neonatologypaediatricsdelaycommunication
VIChome2022

Finding into death of TCW

43y · Female·Neck compression

TCW, age 43, died from neck compression inflicted by her adult son OMP (age 17 at time of incident, now convicted of manslaughter). OMP had intellectual disability (IQ 59), autism spectrum disorder, and hypersexual disor…

psychiatrypsychologysystemdelayfluoxetine
NSWcommunity2021-12-23

Inquest into the deaths of Judith CHRUPALO and Christopher CLEE

73y · Female·Unknown due to decomposition

Mrs Chrupalo, a 73-year-old woman with physical disability, cognitive impairment and alcohol dependency, was discharged from Dubbo Base Hospital on 8 July 2015 against medical advice despite being bedbound and dependent …

geriatric medicinepsychiatrydiagnosticcommunication
NSWhospital2021-12-23

Inquest into the death of Shelley YOUNG

65y · Female·choking on a tangerine

Ms Shelley Young, a 65-year-old woman with long-standing schizoaffective disorder and multiple complications from chronic antipsychotic use including dysphagia and tardive dyskinesia, died from choking on a tangerine whi…

psychiatrygeriatric medicinecommunicationsystemclozapine

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