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VIChospital2012-07-16

Finding into death of Ruben Chand

42y · Male·Hypoxic encephalopathy in the setting of recent acute myocardial infarction with…

Ruben Chand, a 42-year-old male, suffered a fatal hypoxic brain injury during emergency re-intubation in ICU. After an initially reasonable extubation decision, he deteriorated and required urgent re-intubation. The proc…

intensive careanaesthesiaproceduralcommunicationpropofol
VIChospital2012-07-16

Finding into death of Dishita Madamshetty

0y · Female·Hypoxic brain injury in the setting of meconium aspiration syndrome and chorioam…

A full-term neonate born after induction of labour died from hypoxic brain injury secondary to meconium aspiration syndrome and chorioamnionitis. The baby presented in poor condition at delivery with thick meconium prese…

obstetricsneonatologydiagnosticcommunication
QLDcommunity2012-07-05

Patient A

49y · Male·Hanging

A 49-year-old man with bipolar affective disorder and recurrent depression experienced a relapse while in Tasmania and was referred to a community-based Acute Care Team in Queensland in November 2009. Despite his partner…

psychiatrygeneral practicediagnosticcommunicationsertraline
VIChome2012-07-03

Finding into death of Perera and Perera

76y · Male; female·Stab wounds to the arm and chest (Mr Perera); stab wounds to the face and chest …

Two elderly Sri Lankan visitors aged 76 were murdered by their son-in-law following an intervention order requiring his removal from the family home. The deceased visited their daughter in Australia to help with two youn…

communicationsystem
VIChospital2012-07-03

Finding into death of Pruseyus Lily Sharp

0y · Female·Hypoxic brain injury secondary to pneumonia and pulmonary haemorrhage

Pruseyus Sharp was a 39-day-old neonate who died from hypoxic brain injury secondary to pneumonia and pulmonary haemorrhage caused by picornavirus infection. She presented with severe apnoea and minimal preceding symptom…

paediatricsneonatologydelay
WAhome2012-06-29

Inquest into the Death of Operation Lantana

Toxicity from intravenous caesium, DMSO, and other substances administered as pa…

In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr B.'s home in Perth, Western Australia, administering intravenous treatment containing caesium, DMSO, and La…

general practiceoncologydiagnosticproceduralcaesium chloride
QLDhome2012-06-29

Baby M

2y · Male·Hypoxic-ischaemic encephalopathy

Baby M was born at term (35-38 weeks gestation) into a toilet bowl at home on 27 November 2008 after an unrecognised pregnancy. The mother reported no awareness of pregnancy despite a positive pregnancy test earlier in t…

neonatologyparamedicinediagnosticdelay
QLDcommunity2012-06-29

Robinson, Ian; Charlesworth, Natarsha; Hatzidimitriadis; Park, Sang Won; Choi Seongeun

Unknown·Drowning due to entrapment in white-water rapids

Five deaths occurred in white-water rafting accidents in North Queensland between 2007-2009, all involving entrapment and drowning. The coroner examined the adequacy of safety risk management by operators and the regulat…

systemdelay
NSWhome2012-06-28

Roisin Fraser Finding

0y · Female·Hypoxic episode, probably caused by cord entanglement during delivery

A neonate (Roisin) died within 90 minutes of unattended home birth on 27 March 2009. The mother, Janet Fraser, is an advocate for natural birth and rejected all antenatal care despite risk factors including previous caes…

obstetricsmidwiferydiagnosticprocedural
SAhospital2012-06-25

Coroner's Finding: POLKLASER Irmgard Giesela

76y · Female·Aspiration pneumonia complicating surgery for pelvic and spinal fractures on a b…

A 76-year-old woman died from aspiration pneumonia following surgery for pelvic and spinal fractures sustained in a fall on a shopping centre travelator. She fell when her husband lost control of a shopping trolley with …

orthopaedic surgerytrauma surgerysystemdelay
VICaged care2012-06-25

Finding into death of Broughton Hall Inquest

Salmonella infection contributing to deaths in gastroenteritis outbreak

Four elderly residents of Broughton Hall aged care facility died during a 2007 Salmonella gastroenteritis outbreak. A three-day delay in notifying the Department of Health (April 7 to April 10) prevented early identifica…

infectious diseasesgeriatric medicinediagnosticcommunication
QLDhospital2012-06-22

Paton, Daniel William

45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia

A 45-year-old man died from hypoxic-ischaemic encephalopathy following cardiopulmonary arrest 11 hours after elective wrist plate removal surgery. Multiple contributing factors were identified: undisclosed obstructive sl…

anaesthesiapain medicinediagnosticmedicationmorphine
VIChospital2012-06-22

Finding into death of Sebastian Hewitt

2y · Male·Perinatal asphyxia leading to cerebral anoxia and subsequent multi-organ failure

Sebastian Hewitt, born at 36 weeks gestation following maternal ante-partum haemorrhage and abnormal CTG traces, died from perinatal asphyxia leading to cerebral anoxia and multi-organ failure at 3 days old. Critical cli…

obstetricspaediatricsdiagnosticdelay
SAcommunity2012-06-18

Coroner's Finding: JORKOWSKI Natassja Alexandra

19y · Female·asphyxiation

A 19-year-old university student with chronic bilateral uveitis presented to university counselling with depression. She disclosed detailed written suicide plans (helium asphyxiation) to the Head of Counselling, who appr…

psychiatrygeneral practicediagnosticcommunicationescitalopram
SAhospital2012-06-18

Coroner's Finding: GRIPTON William John

62y · Male·multi organ failure due to atypical pneumonia

William Gripton, 62 years old with post-polio syndrome, presented to Kangaroo Island Hospital with upper respiratory tract infection that progressed to atypical pneumonia causing multi-organ failure and death. Critical c…

general medicineintensive carediagnosticcommunicationamoxicillin
NSWhospital2012-06-14

Beverly ann murphy finding & recommendations 0701 08

70y · Female·Hypoxic/Ischaemic Encephalopathy consequent upon Cardiorespiratory Arrest and Co…

Beverly Ann Murphy, 70, underwent hysterectomy for endometrial carcinoma on 2 April 2008 at Royal Hospital for Women. The complex surgery was complicated by iatrogenic small bowel perforations. Post-operatively, wound de…

gynaecologyoncologydiagnosticcommunication
SAhome2012-06-06

Coroner's Finding: Home Birthing - SPENCER-KOCH Tate and HOBBS Jahli Jean and KAVANAGH Tully Oliver

Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: in…

Three neonates died following complications during planned homebirths attended by midwife Lisa Barrett. Tate Spencer-Koch (4790g, macrosomic) died from intrapartum hypoxia caused by shoulder dystocia; delivery was obstru…

obstetricsmidwiferydiagnosticcommunication
VIC2012-06-01

Finding into death of Nathan Fazal Francis

13y · Male·anaphylaxis from ingested peanuts

Nathan Francis, a 13-year-old boy with known severe peanut allergy and asthma, died from anaphylaxis after ingesting beef satay containing peanuts during an Army Cadet camp in the Wombat State Forest. The death resulted …

emergency medicineallergy and immunologysystemcommunicationadrenaline
QLD2012-05-22

S

10y · Female·injuries sustained from being struck by a car

A 10-year-old girl in state child protection care died after being struck by a car while missing from a residential care facility. She had been placed at Lifestyle Solutions despite being outside the facility's service a…

diagnosticsystem
VICmental health2012-05-17

Finding into death of Peter Robin Tully

55y · Male·Hanging

Peter Tully, 55, died by hanging 4 days after discharge from his first psychiatric admission for major depressive disorder with suicidality. He had made 3 suicide attempts in the week before admission. During hospitalisa…

psychiatryemergency medicinecommunicationsystemvenlafaxine

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