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VIC2013-10-21

Finding into death of Danielle Louise Meredith

8y · Female·Multiple injuries sustained in collision between semi-trailer and train at level…

On 5 June 2007, a semi-trailer driven by Christian Scholl collided with a V/Line passenger train at the Kerang level crossing in regional Victoria, killing 11 train passengers and causing severe injuries. This comprehens…

emergency medicinetrauma surgerysystemdelay
VIC2013-10-21

Finding into death of Ercil Jean Webb

79y · 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 the Kerang level crossing, killing 11 train passengers. The driver had traversed this crossing many times in seven years without seeing a train, an…

emergency medicinetrauma surgerysystemdelay
NThome2013-10-15

Inquest into the death of Gwyyneth Cassiopeia-Roennfeldt

36y · Female·Internal injuries consequent on being stabbed repeatedly by Rocky Manu, a man wi…

Jasmine Roennfeldt, a 36-year-old woman with schizoaffective disorder being treated at a community mental health clinic, died from stab wounds inflicted by her flatmate Rocky Manu, who had paranoid schizophrenia. Rocky h…

psychiatrysystemcommunicationantipsychotic medication
NSWcommunity2013-10-11

Inquest into the disappearance and suspected death of Belinda Shirely PEISLEY

19y · Female·Not determined - cause and manner of death could not be established as body was …

Belinda Peisley, aged 19, disappeared on 26 September 1998 after leaving Blue Mountains Hospital in Katoomba, NSW. The coroner found it likely that she is deceased but could not determine the cause or manner of death as …

emergency medicinesystemdelayheroin
QLD2013-10-04

Hempel, Barry Ian; Lovell, Ian Ross

Male·Multiple injuries from aircraft crash; underlying cause - epileptic seizure suff…

Two men died when a Yak-52 aircraft piloted by Barry Hempel crashed into the Pacific Ocean. Evidence suggests Hempel suffered an epileptic seizure mid-flight, rendering him incapacitated and unable to control the aircraf…

neurologyaviation medicinediagnosticcommunicationcarbamazepine
VIC2013-10-02

Finding into death of Daniel Tyson Pelka

19y · Male·aspiration of latex glove; intellectual disability

Daniel Pelka, a 19-year-old with severe intellectual and physical disability, died from aspiration of a latex glove whilst attending a disability day care centre. He had known propensity to place objects in his mouth and…

emergency medicinesystemcommunication
VIChome2013-10-01

Finding into death of Dion Heather

38y · Male·Aspiration of Gastric Content and Combined Drug Toxicity (Methadone, Benzodiazep…

A 38-year-old man died from aspiration of gastric content secondary to combined drug toxicity involving methadone, benzodiazepines, olanzapine and alprazolam. He had confused the day of the week and self-administered two…

addiction medicinegeneral practicesystemdelaymethadone
SAhospital2013-09-30

Coroner's Finding: GIANNINI Pasquale

68y · Male·infarction of the small and large bowel due to superior mesenteric artery thromb…

A 68-year-old man with extensive systemic vascular disease presented with 10 days of nonspecific abdominal pain. Initial presentations at local hospital and GP were attributed to possible gallstones or gastritis based on…

general practiceemergency medicinediagnosticdelayaugmentin duo
VIChospital2013-09-17

Finding into death of Richard Hilton

27y · Male·Hanging

Richard Hilton, a 27-year-old with longstanding bipolar affective disorder and benzodiazepine dependence, presented to Werribee ED three times in two months with suicidal ideation and self-harm attempts. Each time he was…

psychiatryemergency medicinediagnosticcommunicationalprazolam
QLDhospital2013-09-12

Bligh, William John - Non-inquest findings

9y · Male·Disseminated melioidosis

William Bligh, a 9-year-old boy from Palm Island, died from disseminated melioidosis on 24 February 2013. He presented with fever and cough from 2 February, initially assessed as viral illness. Over 11 days, he was revie…

paediatricsinfectious diseasessystemdelayibuprofen
QLD2013-09-11

Quartermain, Robert George

67y · Male·Acute myocardial infarction

Robert Quartermain, a 67-year-old prisoner with chronic obstructive pulmonary disease and previous myocardial infarction, suffered acute myocardial infarction while in custody. He experienced acute breathing difficulties…

cardiologyintensive caredelay
VIC2013-09-06

Finding into death of Philip Stanley Dickson

58y · Male·Multiple injuries from crush injury by falling timber stack

Philip Dickson, a 58-year-old experienced timber yard worker, died when a stack of timber approximately 6-7 metres high collapsed and crushed him while he worked in a drying shed. The coroner found the death was preventa…

occupational and environmental healthforensic medicinesystemdelay
QLDhospital2013-09-05

Sparreboom, Sophie Claire - Non-inquest findings

0y · Female·Cerebral hypoxia due to placental abruption

Sophie Sparreboom died from cerebral hypoxia secondary to placental abruption following emergency caesarean section. Gestational diabetes indicated planned induction at term. At 2050 hours, antepartum haemorrhage and pat…

obstetricsmidwiferysystemcommunicationoxytocin
VIC2013-09-05

Finding into death of Rachel Emma Mead

23y · Female·Blunt force trauma to the head (cranial fractures and pneumocephaly); Motor Vehi…

Rachel Mead, 23, was struck by a vehicle on the Hume Freeway after her car struck a truck wheel that had dislodged from a semi-trailer. The wheel came loose due to inadequate tightening of the spider wheel hub assembly n…

proceduraldelay
WAhome2013-09-05

Inquest into the Death of Doherty, Craig James

39y · Male·propofol toxicity

Craig Doherty, a 39-year-old clinical theatre nurse at Royal Perth Hospital, died from propofol toxicity in June 2010. He had unrestricted access to propofol as an anaesthetic agent and misappropriated it for recreationa…

anaesthesiapharmacysystemdelaypropofol
VIChome2013-08-23

Finding into death of Xavier Hart

4y · Male·hypoxic brain injury complicating out of hospital cardiac arrest (unknown cause)

Xavier Hart, a 4-year-old boy with obstructive sleep apnoea due to adenotonsillar hypertrophy, was found unresponsive and apnoeic at home on 21 December 2011. Despite immediate CPR and intensive resuscitation, he suffere…

paediatricsemergency medicinedelay
VICaged care2013-08-22

Finding into death of MEHMET HASAN

87y · Male·Complications of subdural haematoma and fractured hip following a traumatic inci…

Mr Mehmet Hasan, 87, died from complications of subdural haematoma and fractured hip following an alleged traumatic incident involving staff at Lorikeet Lodge Aged Care on 12 June 2010. Following transfer to hospital, hi…

geriatric medicinegeneral practicesystemcommunication
VIChome2013-08-21

Finding into death of Katarina Sonia Novakovic

47y · Female·INCISED INJURY TO THE NECK

A 47-year-old woman with schizophrenia and recent depressive symptoms died by intentional incised injury to the neck. She had been prescribed escitalopam on 10 September 2010 for emerging depressive illness following her…

psychiatrygeneral practicecommunicationdelayolanzapine
QLD2013-08-20

Tuppurainen, Pekka

Male·traumatic asphyxia due to mine accident (loader operator falling into stope and …

Pekka Tuppurainen, an experienced underground loader operator at George Fisher Mine, died when his loader fell 29 metres into a stope while he was backfilling. He was crushed by backfill material, causing traumatic asphy…

occupational and environmental healthsystemdelay
VICmental health2013-08-20

Finding into death of Hassan Yassin

35y · Male·Hanging

Hassen Yassin, a 35-year-old man with schizophrenia, bipolar affective disorder, and PTSD, died by hanging after absconding from an involuntary psychiatric admission. On 10 January 2011, following a clinical review at Br…

psychiatryemergency medicinecommunicationsystemrisperidone

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