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VIChospital2020-04-16

Finding into death of Jessica Higgins

33y · Female·Hypoxic ischaemic encephalopathy complicating mixed drug toxicity

Jessica Higgins, a 33-year-old woman with chronic pain on high-dose opioids, underwent ketamine infusion with planned opioid rotation to methadone in May 2017. She was discharged on 23 May on methadone 5mg twice daily pl…

pain medicineemergency medicinecommunicationdiagnosticmethadone
TASaged care2020-04-08

Coroner's Finding: Emery, Judith Anne

74y · Female·Chest and abdominal injuries from fall from cliff; possible terminal drowning

Judith Anne Emery, aged 74, died from chest and abdominal injuries sustained in a fall from a cliff near her retirement village, with possible terminal drowning. She was last seen on 24 September 2016 delivering a meal t…

systemcommunication
VIChome2020-04-07

Finding into death of Jesse Stephen Bird

32y · Male·neck compression in the circumstances of hanging

Jesse Bird, a 32-year-old Torres Strait Islander veteran, died by suicide in June 2017 after struggling to navigate the Department of Veterans' Affairs (DVA) compensation system. He served in Afghanistan in 2009, develop…

psychiatryparamedicinesystemcommunicationduloxetine
VIC2020-04-06

Finding into death of Darren Brandon

51y · Male·hypoxic-ischemic encephalopathy due to hanging

Darren Brandon died by hanging in prison on 10 June 2018, two days after arriving at Melbourne Assessment Prison. He was a 51-year-old man with acquired brain injury from a 2003 motorcycle accident, depression, and histo…

psychiatryforensic medicinecommunicationsystemoxycodone
VIC2020-04-06

Finding into death of Robert James Lawerence

29y · Male·Shotgun wound to the head

Robert James Lawrence, a 29-year-old man with complex mental health needs including ADHD, depression, anxiety, Tourette's syndrome, and borderline personality traits, died from a self-inflicted shotgun wound. He held a C…

psychiatrypsychologycommunicationsystem
WAhospital2020-04-02

Inquest into the Death of Valerie KELLY

67y · Female·bronchopneumonia and acute liver failure on a background of liver cirrhosis and …

Valerie Kelly, a 67-year-old woman with cirrhosis, hepatocellular carcinoma, and multiple comorbidities, died at Royal Perth Hospital from bronchopneumonia and acute liver failure. She was in custody at Bandyup Women's P…

hepatologygastroenterologycommunicationsystemolanzapine
QLDhome2020-03-30

Hinder, Nyobi Jade; Hinder, River James & Hinder, Charlie

7y · Female·Explosion caused intentionally by Charlie Hinder; children died instantly from b…

Three deaths resulted from an intentional explosion caused by Charlie Hinder in a caravan containing himself and his two children (ages 4 and 7) during marital separation. Charlie had perpetrated coercive controlling dom…

communicationsystem
VIChospital2020-03-26

Finding into death of Matthew John George

45y · Male·Global cerebral hypoxia following cardio-respiratory collapse due to anaphylaxis…

A 45-year-old man with poorly controlled diabetes, ischaemic heart disease, and recurrent lower limb infections died from anaphylaxis to intravenously administered flucloxacillin. He presented with sepsis secondary to a …

general medicineinfectious diseasescommunicationdiagnosticflucloxacillin
NSWcommunity2020-03-25

Inquest into the death of Tory GANDERTON

3y · Male·respiratory failure, with spinal muscular atrophy an antecedent cause

Tory Ganderton, a 3-year-old boy with spinal muscular atrophy (SMA) Type 1, died of respiratory failure during inter-hospital transfer. Admitted to Shoalhaven Hospital on 7 September 2014 with pneumonia and severe malnut…

paediatricsneurologycommunicationsystemadrenaline
NSW2020-03-25

Inquest into the death of Mahmoud ALLAM

28y · Male·MRSA sepsis

Mahmoud Allam, a 28-year-old man, died from MRSA sepsis whilst in custody at Parklea Correctional Centre. He initially presented with upper respiratory symptoms on 11 June 2016, followed by increasing symptoms including …

infectious diseasesemergency medicinecommunicationsystemflucloxacillin
TAShome2020-03-23

Coroner's Finding: Szemes, Kim Leonie Maree

59y · Female·Unable to determine - body too decomposed at autopsy

Mrs Szemes, a 59-year-old woman with longstanding mental health issues living alone, was found deceased after an interval of approximately 5 months. On 28 May 2018, police attended her home after welfare concerns and cal…

paramedicinepsychiatrycommunicationsystem
VIChome2020-03-20

Finding into death of Janet Foster

55y · Female·Mixed drug toxicity in a woman with cardiomegaly and chronic obstructive airway …

Janet Foster, 55, died from mixed drug toxicity involving heroin/morphine combined with benzodiazepines in the context of cardiomegaly and chronic obstructive airway disease. She was a voluntary palliative care patient a…

emergency medicinegeneral practicecommunicationsystemmorphine
VIChospital2020-03-18

Finding into death of Sommer Bethany Warren

18y · Female·Generalised tonic-clonic seizure and cardiac arrest arising from severe hyperten…

An 18-year-old pregnant woman presented in labour at 41 weeks and 2 days gestation. From 23 September onwards, she experienced intermittent headaches, epigastric pain, proteinuria and peripheral oedema. At 1755 hours on …

obstetricsanaesthesiamedicationdiagnosticropivacaine
VICmental health2020-03-17

Finding into death of Paul Peterson

54y · Male·Neck compression (hanging)

Paul Peterson, 54, died by hanging after leaving a private psychiatric hospital on unapproved leave while on close observations. He was admitted with major depression, suicidal ideation, and opioid dependence. On 1 July …

psychiatrysystemcommunicationcitalopram
NSWhospital2020-03-17

Inquest into the death of Esteban FRANCO-GARCES

11y · Male·Sepsis

An 11-week-old premature infant presented to the ED with fever, lethargy and poor feeding. Despite initial suspicion of sepsis at 1:15pm, antibiotics were not administered until 4pm—a three-hour delay. Key failures inclu…

emergency medicinepaediatricsdiagnosticdelayantibiotics
NSWhome2020-03-16

Inquest into the death of Christina BURGESS

50y · Female·unknown

Christina Burgess, aged 50, was found deceased in her mother's home in August 2018, having likely died between May and August 2018. Autopsy examination could not establish a cause of death due to advanced decomposition. …

psychiatrygeneral practicesystemcommunication
QLD2020-03-10

March 2014 plane crash at Caboolture Airfield

Unknown·Each deceased died as a result of injuries sustained in an aircraft crash: Andre…

Five people died in a Cessna U206G aircraft crash during tandem parachuting operations at Caboolture Airfield on 22 March 2014. The aircraft aerodynamically stalled shortly after take-off, the precise cause could not be …

aviation medicinesystemprocedural
WA2020-03-04

Inquest into the Suspected Death of Charles O'NEILL

38y · Male·death not established

This finding concerns Charles O'Neill, who disappeared from Dampier, Western Australia in April 1969. No medical or clinical issues were involved. The coroner was unable to establish beyond reasonable doubt that Mr O'Nei…

investigationcommunication
NSWaged care2020-03-03

Inquest into the death of Hazel BROCKETT

86y · Female·complications of femoral, radial and ulnar fractures; antecedent cause Alzheimer…

86-year-old Hazel Brockett died from complications of fractures inflicted by a fellow dementia-affected resident in a locked Memory Support Unit (aged care dementia facility). Over months prior, the other resident demons…

geriatric medicinegeneral practicecommunicationdiagnosticbuprenorphine
NSWcommunity2020-03-03

Inquest into the death of Scott CAYIRYLIS

45y · Male·cardiac arrest due to profound blood loss causing hypovolaemia

Scott Cayirylys, aged 45, died from cardiac arrest due to profound blood loss after self-inflicting an arm wound. The death was preventable. Critical delays occurred in emergency response due to multiple system failures:…

emergency medicineparamedicinesystemcommunication

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