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VICcommunity2012-12-21

Finding into death of Benjamin Hall

19y · Male·Multiple injuries from motor vehicle collision (passenger)

Benjamin Hall, age 19, died in a motor vehicle crash when the vehicle he was a passenger in struck a tree at high speed. The driver, Steven Johnstone, a probationary P-plate licence holder, was grossly intoxicated (BAC 0…

systemdelayalcohol
NSWcommunity2012-12-14

Raymond cho findings

Male·Hypoxic brain injury secondary to anaphylaxis caused by walnut ingestion

Raymond Cho, a secondary school student with a known walnut allergy, died of hypoxic brain injury following anaphylaxis at Royal Prince Alfred Hospital on 24 May 2011. He suffered anaphylaxis after ingesting walnuts, lik…

emergency medicineintensive caredelaysystem
VIChospital2012-12-14

Finding into death of Jeanette Brown

66y · Female·Multi-organ failure associated with haemorrhage and sepsis following cholecystec…

Mrs Jeanette Brown, 66, died from multi-organ failure following post-operative haemorrhage after elective laparoscopic cholecystectomy. Arterial clips applied to the cystic artery during surgery were inadequately secured…

general surgeryanaesthesiaproceduralcommunicationamlodipine
VICaged care2012-12-14

Finding into death of Harold Louis

67y · Male·Ischaemic Heart Disease and Coronary Artery Atherosclerosis

Harold Louis, a 67-year-old man with Alzheimer's dementia, ischaemic heart disease, diabetes, and hypertension, was admitted to an aged care facility as 'low care' despite rapidly requiring high-level supervision. Staff …

geriatric medicinecardiologydiagnosticsystem
SAaged care2012-12-13

Coroner's Finding: Kruger Mary Patricia

69y · Female·bronchopneumonia complicating intracranial tumour (meningioma with obstructive h…

Mary Patricia Kruger, aged 69, died of bronchopneumonia complicating a massive subfrontal meningioma with obstructive hydrocephalus. Her death was preventable. During a November 2006 hospital admission for urinary tract …

general practiceneurologydiagnosticcommunicationcarbidopa
SAmental health2012-12-13

Coroner's Finding: Jenkinson Jacqueline Mary

46y · Female·mixed drug toxicity

46-year-old woman with bipolar disorder and chronic suicidal ideation died from mixed drug toxicity involving clozapine (prescribed to her roommate), olanzapine, fluoxetine, oxycodone, and diazepam. She disclosed to her …

psychiatrypsychologycommunicationsystemclozapine
VIChospital2012-12-13

Finding into death of William Andrew Poskitt

31y · Male·Injuries sustained in a fall from height

William Poskitt, a 31-year-old man with recently diagnosed HIV and Pneumocystis carinii pneumonia, died by suicide during a 4-day hospital admission. Despite requesting psychiatric assessment three times and displaying c…

infectious diseasespsychiatrycommunicationdiagnostictrimethoprim
QLD2012-12-12

Ley, Michael David

30y · Male·global hypoxic ischaemic brain injury and aspiration pneumonitis secondary to se…

Michael Ley, aged 30, died from aspiration pneumonia secondary to severe alcohol intoxication after being arrested for public drunkenness. He was brought to a police watch house in an unconscious state. Despite suggestio…

emergency medicineintensive carediagnosticcommunicationalcohol
QLDhospital2012-12-06

McNaught, Judith

69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…

A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consul…

surgeryanaesthesiadiagnosticmedicationmorphine
QLDhome2012-12-06

Bramble, Julie Anne

50y · Female·septicaemia

Julie Anne Bramble, a 50-year-old woman with alcohol dependence and recent drug use, died from septicaemia on 1 April 2011 at her home in Bundaberg. Over 4-5 days prior to death, she developed progressive symptoms includ…

emergency medicineparamedicinedelaycommunicationmethamphetamine
VIChome2012-12-06

Finding into death of Pearl Recht

90y · Female·Type II respiratory failure in the setting of severe respiratory injury followin…

Pearl Recht, a 90-year-old woman living alone with hearing loss and mobility limitations, died from Type II respiratory failure following severe respiratory injury sustained in a house fire on 17 August 2011. She was res…

intensive caregeriatric medicinesystemdelay
VICcommunity2012-11-30

Finding into death of Simon Kirwan

19y · Male·Ruptured aorta post motor vehicle incident

Simon Kirwan, 19, died by motor vehicle collision in circumstances indicating suicide after discharge from involuntary mental health care. He had made three serious suicide attempts within 7 days (overdoses, wrist lacera…

psychiatryemergency medicinediagnosticcommunicationdiazepam
QLDhospital2012-11-28

Hammett, Christopher

47y · Male·Aspiration pneumonia due to or as a consequence of coronary atherosclerosis

Christopher Hammett, a fit 47-year-old, died from aspiration pneumonia with contributing coronary atherosclerosis following routine L5-S1 disc replacement. A critical oxygen desaturation (64%) occurred during transfer fr…

orthopaedic surgeryanaesthesiadiagnosticcommunicationmorphine
VIChome2012-11-28

Finding into death of Justin Michael Galligan

16y · Male·Hypoxic brain injury secondary to skull fracture and extradural haemotoma from b…

Justin Galligan, aged 16, died from hypoxic brain injury due to a skull fracture and extradural haemotoma caused by a single punch at a teenage party. He lost consciousness but was not taken to hospital immediately. Clin…

neurosurgeryemergency medicinedelaycommunication
VIChospital2012-11-26

Finding into death of George Albert John Hutton

73y · Male·ruptured abdominal aortic aneurysm

George Hutton, a 73-year-old man with hypertension, presented to rural emergency department with sudden onset severe abdominal pain while turning his head. Clinical findings were atypical: he appeared calm, had relativel…

emergency medicinegeneral practicediagnosticdelaycoversyl plus
VIC2012-11-16

Finding into death of Rebecca Lazarus

25y · Female·Stab wounds to the chest and abdomen

Rebecca Lazarus, a 25-year-old woman with intellectual disability, was fatally stabbed by her partner Travis Cooke who had chronic treatment-resistant paranoid schizophrenia, was on a Community Treatment Order, and had a…

psychiatryemergency medicinecommunicationsystemclozapine
SAcommunity2012-11-15

Coroner's Finding: Edgar Lauren Michelle

28y · Female·Multi-organ failure due to Clostridium perfringens myonecrosis complicating lipo…

Lauren Edgar, a 28-year-old woman, died of multi-organ failure from Clostridium perfringens myonecrosis (gas gangrene) following a liposuction procedure performed by Dr K. on 5 March 2008. She presented to hospital on 8 …

plastic and reconstructive surgerygeneral practicediagnosticcommunicationpanadol/paracetamol
QLDhome2012-11-14

Galeano, Antonio Carmelo

39y · Male·Excited delirium, probably caused by amphetamine toxicity-induced psychosis. Dea…

Antonio Carmelo Galeano died in police custody on 12 June 2009 after a protracted struggle and multiple taser activations. He had acute amphetamine toxicity and was displaying excited delirium—a high-risk medical emergen…

emergency medicinepsychiatryproceduralcommunicationamphetamine
NSWcommunity2012-11-14

Inquest into the death of Roberto Laudisio CURTI

21y · Male·undetermined causes, in the course of being restrained by members of the NSW Pol…

Roberto Laudisio Curti, a 21-year-old Brazilian, died on 18 March 2012 during police restraint in Sydney after consuming LSD which induced a psychotic state. After a convenience store incident was misclassified as an arm…

psychiatrytoxicologycommunicationsystemLSD
NSWhospital2012-11-01

Michelle Mcilquham Findings

28y · Female·acute streptococcus pneumonia meningitis with left-sided otitis media as anteced…

Michelle McIlquham, 28 years old, died from undiagnosed acute bacterial meningitis (streptococcus pneumonia) that developed from a middle ear infection. She presented to Bankstown Hospital Emergency Department with a fir…

emergency medicinediagnosticcommunication

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