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QLDhospital2019-07-24

Mr P - Non-inquest findings

47y · Male·Pulmonary thrombo-embolism secondary to deep vein thrombosis in setting of morbi…

A 47-year-old man with morbid obesity presented with respiratory failure, productive cough, and calf swelling. His GP appropriately suspected both pneumonia and pulmonary embolism (PE), requesting urgent CTPA. At Townsvi…

intensive careemergency medicinediagnosticcommunicationheparin
NSWhospital2019-07-22

Inquest into the death of Nicholas Wells

24y · Male·Peritonitis secondary to a perforation of the small bowel

Nicholas Wells, a 24-year-old man, died from peritonitis secondary to small bowel perforation sustained in a motor vehicle accident. Although he was suspected of having a bowel injury at 11am on admission, he was placed …

emergency medicinesurgerydiagnosticcommunicationmethamphetamine
WAcommunity2019-07-17

Inquest into the Death of Mark Quenton FLEURY

38y · Male·ligature compression of the neck (hanging)

Mark Quenton Fleury, a 38-year-old man with paranoid schizophrenia, died by suicide on 14 February 2016 while subject to a Community Treatment Order. In the final week of his life, he presented to emergency services and …

psychiatryemergency medicinecommunicationsystemrisperidone
VIChospital2019-07-17

Finding into death of Vincenzo Bellina

48y · Male·Septicaemia in a man with a psoas abscess; Diabetes mellitis

A 48-year-old man with insulin-dependent diabetes, mild cognitive impairment, and chronic alcoholic liver disease was admitted with sepsis from a psoas abscess. After 15 days of intravenous antibiotics, he refused IV con…

surgeryinfectious diseasescommunicationsystemclindamycin
VIC2019-07-17

Finding into death of Fiona Warzywoda

33y · Female·Stab wounds to the chest (tension hemopneumothorax resulting from stab wounds)

A 33-year-old woman was fatally stabbed by her separated de facto partner following a 18-year relationship marked by escalating family violence. Multiple agencies had contact with the victim in the weeks before her death…

paediatricspsychiatrydiagnosticcommunication
QLDaged care2019-07-12

Fenech, George - Non-inquest findings

89y · Male·Congestive heart failure due to or as a consequence of ischaemic cardiomyopathy

George Fenech, 89, died of ischaemic cardiomyopathy complicated by congestive heart failure after a fall at a nursing home. He suffered a cervical spine injury (C1-C2 subluxation) and head laceration during an unwitnesse…

geriatric medicineemergency medicinecommunicationdelaywarfarin
VIC2019-07-05

Finding into death of Hizir Ferman

35y · Male·Cardiorespiratory arrest in the setting of acute agitation and physical and chem…

Hizir Ferman, aged 35, died at Middleton Prison following forcible extraction from his room by SESG officers using CS gas and physical restraint. He was held prone with hands cuffed behind him, a shield on his back, and …

correctional healthemergency medicinecommunicationsystem
NSW2019-07-05

Inquest into the death of Rebecca Maher

36y · Female·respiratory depression after loss of consciousness caused by mixed drug toxicity…

Rebecca Maher, a 36-year-old Aboriginal woman, died from respiratory depression caused by mixed drug toxicity (high levels of Alprazolam and Methadone) while detained as an intoxicated person at Maitland police station. …

general practicepharmacydiagnosticmedicationalprazolam
NSWhome2019-07-05

Inquest into the death of Levai

7y · Male·Blunt force head injury with bilateral acute subdural haemorrhage, hypoxic/ischa…

Levai, a 7-year-old boy with learning difficulties, died from blunt force head trauma inflicted by his mother's boyfriend Kodi Maybir on 20 May 2013. The coroner identified systematic failures by NSW Police and FACS. Pol…

paediatricsforensic medicinediagnosticcommunication
NSW2019-07-04

Inquest into the death of RP and DJ

Male·RP: fatal pressure to the neck; DJ: neck compression

Two remand inmates died in separate incidents at the Metropolitan Remand and Reception Centre after being placed with mentally ill cellmates exhibiting acute psychosis. RP died in 2010 from injuries inflicted by cellmate…

psychiatrydiagnosticcommunicationquetiapine
VICcommunity2019-06-28

Finding into death of Paul Simon Taouk

40y · Male·Carbon Monoxide Poisoning

Paul Taouk, a 40-year-old with schizophrenia and substance use disorder, died from carbon monoxide poisoning after absconding from a community mental health clinic on 23 December 2015. He had been assessed as unsafe and …

psychiatryemergency medicinecommunicationsystempaliperidone
VIChospital2019-06-26

Finding into death of Trajce Laboski

27y · Male·Injuries sustained in descent from height

A 27-year-old man with schizophrenia was brought to Northern Hospital ED by police under Mental Health Act section 351 after threatening suicide and injecting testosterone. The Emergency Department doctor (Dr K.) assesse…

emergency medicinepsychiatrydiagnosticproceduraltestosterone
WAhospital2019-06-21

Inquest into the Death of Gerda Theresia DUNKEL

44y · Female·pulmonary thromboembolism in a woman with likely myeloproliferative neoplasm

A 44-year-old previously healthy woman with BMI 30.5 and minimal comorbidities (snoring, back pain, knee pain) underwent elective sleeve gastrectomy for weight loss. Nine days post-op she presented with splenic rupture r…

general surgerybariatric surgerydiagnosticcommunicationheparin
SAhospital2019-06-21

Coroner's Finding: COOK Janet Ann

79y · Female·multi-organ failure as a result of ischaemic and valvular heart disease with uri…

Janet Ann Cook, aged 79, died of multi-organ failure complicated by hydromorphone toxicity on 30 September 2015. She was mistakenly administered 16mg hydromorphone intended for another patient (room 28 vs room 26) on 21 …

cardiologypalliative caremedicationcommunicationhydromorphone
ACThome2019-06-20

AN INQUEST INTO THE DEATH OFMARK ANTHONY O’BRIEN

58y · Male·Heroin toxicity

58-year-old man with chronic back pain, paranoid schizophrenia, and decades-long prescription opioid and benzodiazepine abuse died from heroin toxicity. He had been successfully withdrawn from opioids (MS Contin, Endone)…

psychiatrypain medicinesystemcommunicationheroin
QLDhospital2019-06-20

Burrell, Michael Leslie

58y · Male·Multifocal hepatocellular carcinoma due to cirrhosis of the liver due to hepatit…

Michael Leslie Burrell, a 58-year-old prisoner with terminal hepatocellular carcinoma secondary to hepatitis C and cirrhosis, died in the Princess Alexandra Hospital Secure Unit. He was admitted to the ED on 17 September…

emergency medicinegastroenterologydiagnosticcommunicationmorphine
NSW2019-06-19

Inquest into the death of M A

44y · Male·Hanging

A 44-year-old man died by hanging in a prison cell two days after reception. Despite disclosing a history of depression and recent heavy methamphetamine use, he was not prescribed his usual escitalopram medication, was p…

psychiatrygeneral practicediagnosticcommunicationescitalopram
NSWhospital2019-06-14

Inquest into the death of Melissa King

33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…

Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraem…

intensive careendocrinologydiagnosticcommunicationglycoprep
WAhome2019-06-12

Inquest into the Death of Child L (Name Subject to Suppression Order)

13y · Male·Epileptic seizure with aspiration

Child L, a 13-year-old boy with autism, cognitive impairment and poorly controlled generalised epilepsy, died from sudden unexpected death in epilepsy (SUDEP) with aspiration. His seizures remained refractory despite app…

neurologypaediatricsmedicationcommunicationlevetiracetam
QLDcommunityPodcast2019-06-12

Brown, Holly Winta

17y · Female·Arrhythmia due to myocardial scarring secondary to past myocarditis, possibly fr…

Holly Brown, 17, died of fatal cardiac arrhythmia from undiagnosed heart scarring likely due to childhood rheumatic fever. She collapsed at a regional mass gathering event (2000+ attendees) in remote Laura, Queensland. C…

emergency medicinegeneral practicesystemcommunicationadrenaline

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