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VICcommunity2013-01-31

Finding into death of Stuart Beverley

31y · Male·Hanging

A 31-year-old man with borderline personality disorder presented to mental health services after a suicide attempt on 30 March 2005, discharged after psychiatric assessment at Maroondah Hospital ED. Following several cri…

psychiatryemergency medicinecommunicationdelaydiazepam
VIC2013-01-30

Finding into death of Burnley Tunnel Deaths

Male·Kennard: Multiple injuries; Sporn: Effects of fire; McDonald: Effects of fire

Three people died in a catastrophic collision and fire in the Burnley Tunnel on 23 March 2007, caused by a truck driver (Kalwig) operating his vehicle with inadequate attention. The driver was convicted of dangerous driv…

delay
QLDmental health2013-01-25

SH and AW

25y · Female·Chest injuries due to fall from height

Two psychiatric inpatients (SH, 25-year-old female; AW, 24-year-old male) died by suicide by jumping from the Buranda car park across from Princess Alexandra Hospital's Mental Health Unit within a 10-month period despite…

psychiatrydiagnosticcommunicationhaloperidol
QLDhospital2013-01-18

Ryan, Adam Trent

30y · Male·asphyxia due to hanging (suicide)

30-year-old Adam Trent Ryan died by suicide via hanging in July 2009. Multiple systemic failures preceded his death. The Community Mental Health Service failed to communicate Mr Ryan's past suicide attempt to the hospita…

psychiatrygeneral practicecommunicationdocumentationsertraline
WAhospital2013-01-17

Inquest into the Death of Aslett, Wendy May

60y · Female·Multiple organ failure following hemorrhage from penetration of the femoral arte…

Wendy May Aslett, aged 60, died on 29 October 2010 from multiple organ failure following hemorrhage from a femoral artery puncture sustained during coronary angiography on 21 October 2010. An Angio-Seal device was used t…

cardiologyemergency medicinediagnosticcommunicationprasugrel
WAhospital2013-01-17

Inquest into the Death of Mckay-Hall, Julienne Maria

46y · Female·Complications following cardiorespiratory arrest in association with an air embo…

A 46-year-old woman died from air embolism during a gastroscopy to manage complications from bariatric surgery. The initial laparoscopic sleeve gastrectomy on 9 November 2007 had a staple misfire that was inadequately re…

general surgerybariatric surgerydiagnosticcommunicationmorphine
WAhospital2013-01-17

Inquest into the Death of Wendy May Aslett

60y · Female·Multiple organ failure following haemorrhage from penetration of the femoral art…

A 60-year-old woman died from multiple organ failure caused by uncontrolled bleeding from an arterial puncture sustained during coronary angiography. Although the procedure itself was uncomplicated and an Angio-Seal devi…

cardiologygeneral practicediagnosticcommunicationaspirin
VICcommunity2013-01-16

Finding into death of Mark Robert Scott

41y · Male·Effects of Fire

Mark Robert Scott, a 41-year-old man with chronic pain, substance addiction, and recent depressive illness, was admitted to Frankston Hospital on 15 July 2011 following suicidal ideation. During admission, he disclosed t…

psychiatrygeneral practicedelaycommunicationmethadone
VIChome2013

Finding into death of Barabara Lubik

36y · Female·stab injury to neck with transection of left common carotid artery

Barbara Lubik, a 36-year-old Polish immigrant, was fatally stabbed in the neck by her husband Peter Lubik during a domestic dispute on 25 January 2009. The autopsy confirmed the stab wound transected the left common caro…

emergency medicineforensic medicinecommunicationsystem
VIC2013

Finding into death of Noel Imbrogno

43y · Male·Multiple injuries sustained in a motor vehicle incident (passenger)

A 43-year-old man died from multiple injuries sustained when the truck he was a passenger in collided with a power pole. The driver lost control after the driver's seat collapsed due to pre-existing mechanical failures i…

systemdelay
WAhome2013

Inquest into the Death of Stevens, Malachi Isaac and Stevens, Lochlan James

10y · Male·Unascertainable

Two young children, Malachi (10 months) and Lochlan (2 years), died on 7-8 November 2008 in their mother's home en suite, with cause of death unascertainable. The mother claimed to have blacked out for approximately 10 h…

paediatricsforensic medicinesystemdelay
WAhome2013

Inquest into the Death of Roll, Robert

75y · Male·Unascertainable due to advanced decomposition; likely lung cancer

Robert Roll, a 75-year-old socially isolated pensioner with terminal lung cancer, discharged himself from Royal Perth Hospital on 6 July 2009 against planned palliative care arrangements. Although Silver Chain Hospice ar…

palliative caregeriatric medicinecommunicationsystem
WA2013

Inquest into the Death of Kaniva Vessel

24y · Male·Immersion (drowning)

This coronial finding concerns 17 deaths from drowning following the sinking of the vessel Kaniva in international waters north of Christmas Island on 21 June 2012. The vessel, carrying approximately 212 asylum seekers a…

communicationsystem
WA2013

Inquest into the Death of Hale, David Maxwell

32y · Male·complications of metastatic pancreatic cancer

A 32-year-old male prisoner died from metastatic pancreatic cancer at a hospice. Pancreatic cancer was diagnosed shortly after incarceration when jaundice was detected. He received appropriate oncology treatment and pall…

oncologypalliative caredelaysystem
WA2013

Inquest into the Death of Ms D

39y · Female·Septic shock and nosocomial pneumonia secondary to pentobarbital (Nembutal) over…

A 39-year-old woman with major depression and Cluster B personality traits died by suicide in Mexico following a pentobarbital overdose on 28 April 2008, resulting in septic shock and nosocomial pneumonia. She had been a…

psychiatryintensive caresystemdelaypentobarbital
WA2013

Inquest into the Death of Brasier, Thomas

3y · Male·Consistent with Multiple Injuries

Thomas Michael Brasier, age 3, died from multiple injuries sustained when a brick pillar supporting a veranda roof at a holiday cottage collapsed while he was on a hammock. The pillar was built in 1975 without proper str…

systemdelay
WAcommunity2013

Inquest into the Death of Bradanovich, Anthony John

35y · Male·exertional heat stroke

A 35-year-old truck driver, on his first day of employment with Cartwright Holdings, became lost en route to Jundee Mine site in remote Western Australia. After missing a turnoff on the Gunbarrel Highway and becoming bog…

occupational and environmental healthemergency medicinesystemcommunication
WAhome2013

Inquest into the Death of Box, James Gregory

3y · Male·Immersion (drowning)

A 3-year-old boy drowned in a backyard swimming pool after gaining unsupervised access through a malfunctioning sliding security door. The door was required by law to be self-closing but repeatedly jammed, prompting the …

systemcommunication
VICcommunity2012-12-21

Finding into death of Steven Johnstone

19y · Male·Multiple injuries sustained in motor vehicle collision (driver); impact of vehic…

Steven Johnstone, a 19-year-old P-plate driver with a blood alcohol level of 0.19% (nearly four times the probationary driver limit), drove at extreme speeds of 150-200 km/h through residential areas on 17 January 2010, …

systemdelayalcohol
VIC2012-12-21

Finding into death of Mathew Lister

17y · Male·Multiple injuries from motor vehicle collision

A 17-year-old male died from multiple injuries sustained in a motor vehicle collision when the car he was a passenger in struck a tree at high speed. The driver, a 19-year-old on probationary licence, was significantly i…

systemdelayalcohol

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