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TAScommunity2020-11-23

Coroner's Finding: Ridgeon Beryl Jean

83y · Female·haemopericardium due to ruptured acute myocardial infarction with underlying cor…

An 83-year-old woman presented to Mersey Community Hospital with vomiting and suspected gastroenteritis. An ECG was performed as a routine process and clearly demonstrated acute ST-elevation myocardial infarction (STEMI)…

emergency medicinecardiologydiagnosticcommunicationmetoclopramide
VIChome2020-11-20

Finding into death of Baby S

1y · Male·head injury

Baby S, a 12-month-old boy, died from head injuries inflicted by his mother's de facto partner, Mr B, while the mother was away obtaining heroin. The child had multiple previous injuries documented by childcare staff and…

paediatricsgeneral practicediagnosticcommunicationheroin
NSWhospital2020-11-20

Inquest into the death of Melissa Stokes

49y · Female·Fatal Cardiac Arrhythmia

Melissa Stokes, 49, died from a fatal cardiac arrhythmia one day after successful abdominal hysterectomy and sling surgery. The coroner found the cause was not opioid-induced respiratory depression despite post-operative…

anaesthesiagynaecologycommunicationdelaytramadol
VICcommunity2020-11-19

Finding into death of Bhavita Patel

Blunt force trauma from impact with motor vehicle

Six people were fatally struck by a stolen vehicle deliberately driven through Bourke Street Mall in Melbourne CBD on 20 January 2017: Matthew Poh Chuan Si (33), Thalia Hakin (10), Yosuke Kanno (25), Jess Mudie (22), Zac…

systemcommunication
VICcommunity2020-11-19

Finding into death of Jess Mudie

Traumatic injuries sustained when struck by stolen motor vehicle (principally he…

Finding into six deaths resulting from the Bourke Street mass casualty incident on 20 January 2017 in Melbourne, Victoria. James Gargasoulas drove a stolen vehicle into crowds in Bourke Street Mall, killing Matthew Poh C…

systemcommunication
WA2020-11-19

Inquest into the Death of Levi Shane Clement CONGDON

27y · Male·methylamphetamine toxicity

Levi Shane Clement Congdon, a 27-year-old male, died from methylamphetamine toxicity on 13 November 2017 at Royal Perth Hospital during a police search warrant execution. He ingested a fatal dose of methylamphetamine, re…

emergency medicinetoxicologycommunicationsystemmethamphetamine
VIChome2020-11-16

Finding into death of Hilton Davis

50y · Male·mixed drug (oxycodone and methadone) and ethanol toxicity

A 50-year-old Torres Strait Islander man died from mixed drug (oxycodone and methadone) and ethanol toxicity in the context of family violence and suicidality. He had a 7-year history of suicide attempts and mental healt…

general practiceforensic medicinecommunicationsystemoxycodone
NSWcommunity2020-11-16

Inquest into the death of D B

39y · Male·Self-inflicted death by hanging

A 39-year-old man with longstanding Bipolar I Disorder died by hanging on 28 December 2017, shortly after police attended a domestic disturbance at his mother's home. He had expressed suicidal ideation to his treating ps…

psychiatryemergency medicinecommunicationsystem
VIChome2020-11-10

Finding into death of Mr BT

27y · Male·Hanging

A 27-year-old carpenter with a long history of depression, suicidality, and substance abuse died by hanging. He had experienced recent family violence incidents as both perpetrator and victim in relationships, leading to…

psychiatrygeneral practicecommunicationsystemvenlafaxine
VICcommunity2020-11-06

Finding into death of Jessica Morgana Wilby

45y · Female·Compression of the neck in circumstances of hanging

Jessica Morgana Wilby, aged 45, a highly accomplished Principal In House Solicitor at the Coroners Court of Victoria with extensive qualifications and excellent performance record, took her life by hanging on 7 September…

psychiatrypsychologysystemcommunicationantidepressants
TAScommunity2020-11-05

Coroner's Finding: Marshall, Eric Craig

19y · Male·Chest and abdominal injuries sustained when a forklift rolled over and trapped h…

A 19-year-old farm worker with intellectual disability died when a forklift he was operating rolled over on a gravel laneway, trapping him beneath the roll cage. Mr. Marshall had received informal training in August 2014…

systemsupervision
WAcommunity2020-11-04

Inquest into the Death of Andrew John KEY

49y · Male·incised injury to the neck

Andrew Key, a 49-year-old man with bipolar affective disorder, died by suicide on 11 August 2015 after self-inflicting a neck injury while being restrained by police. Clinical lessons emerged regarding mental health asse…

psychiatryemergency medicinecommunicationsystemquetiapine
NSWcommunity2020-10-30

COOK Grant Findings

28y · Male·Hypoxic brain injury as a result of a respiratory arrest, after inadequate respi…

Grant Cook, aged 28, collapsed during a rugby league game after a tackle caused him to fall and hit his head. He suffered a grand mal seizure with snoring/obstructed breathing, leading to respiratory arrest, cardiac arre…

paramedicineintensive carecommunicationdiagnosticadrenaline
SAhospital2020-10-30

Coroner's Finding: VELT Hank Jakob

65y · Male·ischaemic and hypertensive heart disease with contributing acute cholecystitis (…

A 65-year-old man with hypertension presented with acute cholecystitis, underwent laparoscopic cholecystectomy, and initially recovered well. On post-operative day 7, he experienced chest pain radiating to his jaw. Two E…

general surgerycardiologydiagnosticcommunication
NSW2020-10-23

Inquest into the death of Ye Chiu

67y · Male·Head injuries sustained from a fall from the upstairs landing in Goldsmith G Blo…

Ye Chiu, a 67-year-old Chinese-speaking prisoner on remand, died by suicide in prison on 6 February 2017 after falling head-first from a landing. He had a complex psychiatric history including anxiety, depression, hypona…

psychiatryemergency medicinesystemcommunicationparoxetine
VIChospital2020-10-21

Finding into death of Anthony Lansell Churches

70y · Male·Cyanide Toxicity

Anthony Lansell Churches, a 70-year-old man with a history of substance use and criminal offences, died from cyanide toxicity after absconding from St Vincent's Hospital's Emergency Department. He had been placed on an i…

emergency medicinepsychiatrycommunicationsystemcyanide
VIChospital2020-10-19

Finding into death of BABY FF

2y · Male·Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstr…

A term infant died on day 2 of life from hypoxic-ischaemic encephalopathy and intracranial haemorrhage following obstructed labour requiring emergency caesarean section. The mother presented in spontaneous labour at 39 w…

obstetricsneonatologymonitoringcommunicationoxytocin
WAhospital2020-10-19

Inquest into the Death of Renee Desiree RUYZING

21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg

A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…

orthopaedic surgeryemergency medicinediagnosticmedicationenoxaparin
VIChospital2020-10-13

Finding into death of BABY C

0y · Male·Myocarditis

Baby C, a 5-month-old infant, died from myocarditis (viral heart inflammation) after presenting to Sunshine Hospital Emergency Department with fever, breathing difficulty, and cyanosis. He waited 1 hour 52 minutes before…

emergency medicinepaediatricsdiagnosticdelayparacetamol
TASmental health2020-10-09

Coroner's Finding: Le Roy, Carole Ann

40y · Female·hypoxic encephalopathy due to asphyxia from hanging

A 40-year-old woman with extensive mental health history including OCD, complex trauma, severe depression, and recurrent suicidal ideation was admitted to an open psychiatric unit after expressing suicidal intent. Despit…

psychiatryintensive carediagnosticsystem

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