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VIC2013-12-20

Finding into death of Niel Fraser Buckton

40y · Male·Unascertained

Niel Buckton, a 40-year-old qualified civil engineer, died after entering a live sewer access chamber at the Blue Hills Estate in Pakenham on 25 January 2005. He was directed by his supervisor to inspect rectification wo…

occupational and environmental healthpsychiatrydiagnosticsystem
VICaged care2013-12-18

Finding into death of Caterina Montalto

76y · Female·Immersion (with underlying cause undetermined in circumstances of a fall into a …

76-year-old woman with vascular dementia and wandering behaviour was found submerged in a courtyard water fountain at an aged care facility after a fall. She remained unattended in a hazardous area for approximately 51 m…

geriatric medicinegeneral practicecommunicationsystemdiazepam
QLD2013-12-11

Woods, Gavin Lyle

46y · Male·Consistent with exhaust fumes toxicity (suicide by carbon monoxide)

A 46-year-old teacher, Gavin Lyle Woods, died by suicide after prolonged workplace stress and an undertreated major depressive disorder. He had been a deputy principal at Burpengary State School for only five months. Cli…

psychiatrygeneral practicecommunicationsystemescitalopram
QLD2013-12-06

Sims, Desmond Arthur

62y · Male·Non-small cell lung carcinoma with metastases

Desmond Sims, a 62-year-old prisoner, died from advanced non-small cell lung carcinoma with metastases. He was diagnosed with lung cancer in February 2009 at Princess Alexandra Hospital (PAH) but was lost to follow-up fo…

respiratory medicineoncologysystemcommunication
WAhospital2013-11-29

Inquest into the Death of Jones, Wilma Ray

75y · Female·Abdominal infection following surgery (repair of recurrent umbilical hernia) - s…

Wilma Ray Jones, 75, died of abdominal infection and sepsis following uncomplicated umbilical hernia repair. Post-mortem revealed ischaemic bowel with infarction, likely caused by superior mesenteric artery occlusion tri…

general surgeryanaesthesiadelaysystemephedrine
VICcommunity2013-11-28

Finding into death of Felix Hua

14y · Male·Drowning

Felix Hua, a 14-year-old with severe autism and intellectual disability, drowned in the Yarra River while under respite care supervision in May 2009. The death resulted from multiple systemic failures: a care worker (Mr …

systemcommunication
VIChome2013-11-27

Finding into death of Andrew Gilmore

17y · Male·intra-abdominal haemorrhage complicating partial pancreatectomy for traumatic pa…

Andrew Gilmore, a 17-year-old fit and well boy, suffered traumatic pancreatic rupture from a football injury on 9 May 2009. Distal pancreatectomy was performed at Alfred Hospital on 11 May. He was discharged to Hospital …

general surgeryemergency medicinecommunicationdelayoxycodone
NT2013-11-20

Inquest into the death of Sara Lorraine Hampel

21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…

Sara Hampel, 21 years old, died from sepsis caused by necrotising fasciitis (Group A Streptococcus) on 14 October 2011, presenting 8 days post-partum with severe leg pain and multiple signs of sepsis. Critical failures i…

obstetricsemergency medicinediagnosticcommunicationparacetamol
VIC2013-11-15

Finding into death of Melissa Ann Ryan

32y · Female·Head injuries post motor vehicle incident (driver)

Melissa Ryan, 32, died from head injuries sustained in a collision on the Monash Freeway when the truck she was following struck her vehicle. She was engaged in a lengthy mobile phone conversation (hands-free) at the tim…

delay
WAhospital2013-11-12

Inquest into the Death of Ford, Valma May Ruth

77y · Female·Complications following a recent fracture and surgical repair of the right hip i…

A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Ke…

orthopaedic surgeryemergency medicinediagnosticsystemwarfarin
WAhospital2013-11-08

Inquest into the Death of Nielson, Melissa Ann

24y · Female·hypoxic brain injury following unexplained cardiorespiratory arrest

A 24-year-old female with brittle Type 1 diabetes and multiple comorbidities presented to Joondalup ED with a rapidly spreading blistering rash on 3 September 2009. Dr C. appropriately identified a potentially serious de…

emergency medicinedermatologycommunicationdiagnosticcefalexin
TAS2013-11-06

Coroner's Finding: Sullivan, Craig

18y · Male·rupture of a left frontal cerebral abscess

An 18-year-old male detainee at Ashley Youth Detention Centre died from rupture of a left frontal cerebral abscess likely caused by sinus infection. Craig was admitted on remand in early October 2010 and presented with i…

infectious diseasesneurosurgerysystemdelay
VIC2013-10-21

Finding into death of Jaesok Lee

26y · Male·Multiple injuries from collision between semi-trailer and train at level crossin…

On 5 June 2007, a semi-trailer collided with a V/Line passenger train at the Kerang level crossing, killing 11 passengers. The driver had crossed this crossing hundreds of times without seeing a train, was familiar with …

emergency medicinetrauma surgerysystemdelay
VICcommunity2013-10-21

Finding into death of Margaret Eunice Wishart

78y · Female·Blunt force trauma to the head caused by a compressor from a refrigeration unit …

Margaret Wishart, aged 78, died instantly on 5 June 2007 when a semi-trailer driven by Christian Scholl collided with a V/Line passenger train at a level crossing near Kerang, Victoria. The compressor from the refrigerat…

emergency medicinetrauma surgerysystemprocedural
VICcommunity2013-10-21

Finding into death of Matthew John Stubbs

13y · Male·chest and abdominal injuries sustained in collision between semi-trailer and tra…

A 13-year-old boy, Matthew Stubbs, died when a semi-trailer collided with a V/Line passenger train at the Kerang level crossing on 5 June 2007, killing 11 train passengers total. The driver failed to see the train despit…

emergency medicinetrauma surgerysystemdelay
VIC2013-10-21

Finding into death of Stephanie Louise Meredith

46y · Female·Multiple injuries sustained in collision between semi-trailer and train; tension…

On 5 June 2007, a semi-trailer collided with a V/Line passenger train at Kerang level crossing in Victoria, killing 11 train passengers immediately and one more (Harold Long) during transfer. The driver (Mr Scholl) faile…

emergency medicinetrauma surgerysystemdelaymorphine
VIC2013-10-21

Finding into death of Chantal Rose Meredith

5y · Female·Multiple injuries sustained in a collision between a semi-trailer and a V/Line p…

A semi-trailer collided with a V/Line passenger train at a level crossing near Kerang on 5 June 2007, killing 11 passengers instantly or within hours. The collision was caused by a heavy vehicle driver unfamiliar with th…

emergency medicinetrauma surgerysystemdelay
VIClevel crossing collision between vehicle and train2013-10-21

Finding into death of Nicholas William Parker

32y · Male·Multiple injuries sustained when struck by semi-trailer at level crossing

In 2007, a semi-trailer collided with a V/Line train at the Kerang level crossing in regional Victoria, killing 11 train passengers. The driver, Christian Scholl, did not see the flashing red-filtered incandescent lights…

emergency medicinetrauma surgerydiagnosticsystem
VICcommunity2013-10-21

Finding into death of Rosanne Eve McMonnies

17y · Female·Multiple injuries sustained in collision between semi-trailer and train

On 5 June 2007, a semi-trailer collided with a V/Line passenger train at Kerang level crossing in Victoria, killing 11 passengers. The driver was familiar with the crossing but failed to see flashing red warning lights a…

emergency medicinetrauma surgerysystemdelay
VIC2013-10-21

Finding into death of Geoffrey Ian McMonnies

50y · Male·Multiple injuries sustained in collision between semi-trailer and train

A comprehensive coronial investigation into 26 deaths from 12 level crossing collisions in Victoria (2002-2009), with particular focus on the Kerang incident (5 June 2007) in which 11 train passengers died when a semi-tr…

emergency medicinetrauma surgerysystemdiagnostic

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