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VICcommunity2012-03-01

Finding into death of K

33y · Male·complications from blunt force trauma to head consequent upon being struck by a …

A 33-year-old man with long-standing substance abuse and acute methadone withdrawal presented with suicidal ideation on the morning of 11 February 2007. The Crisis Assessment and Treatment (CAT) Team assessed him at 5pm …

psychiatrygeneral practicediagnosticcommunicationmethadone
WAhospital2012-03

Inquest into the Death of Troy

63y · Female·Intra-cerebral bleed secondary to thrombocytopenia in a person with prolymphocyt…

Josephine Troy, 63, died on 14 February 2006 at Bunbury Regional Hospital from an intracerebral bleed secondary to thrombocytopenia (platelet count of 1) arising from prolymphocytic leukaemia. She had been in remission f…

haematologyintensive carecommunicationdelaychemotherapy
VIC2012-02-29

Finding into death of Keith Phillip Dickman

56y · Male·Head injuries sustained in a fall from a height

Keith Dickman, a 56-year-old experienced plumber, died from severe head injury sustained in a fall from a 2-metre 'A' frame ladder while installing air conditioning ducting at height in a ceiling cavity. Working on the f…

occupational and environmental healthoccupational therapysystemcommunication
VIC2012-02-28

Finding into death of Robert Alan How

62y · Male·Multiple injuries and effects of fire from an aeroplane crash resulting from str…

Robert Alan How, a 62-year-old pilot with 600 flight hours, died when his Cessna struck unmarked power lines at 27 metres altitude while performing low-level flying near his property. He had no low-flying qualifications.…

aviation medicinesystemdelay
WA2012-02-23

Inquest into the Deaths of SIEV 221 Victims (Christmas Island)

Drowning from immersion in the sea; for those whose bodies were not recovered, d…

SIEV 221, a fishing vessel carrying 92 people, sank on Christmas Island on 15 December 2010, killing 50 asylum seekers and crew. Thirty bodies were recovered; 20 remain missing. The vessel lacked adequate lifejackets, sa…

systemdelay
QLDhospital2012-02-21

Vaggs, Lyji

28y · Male·hypoxic brain injury sustained during restraint in the foyer of the Acute Mental…

Lyji Vaggs, a 28-year-old Aboriginal man with schizophrenia, died from hypoxic brain injury sustained during restraint at Townsville Hospital's Acute Mental Health Unit on 13 April 2010. He had declined admission at ED o…

psychiatryemergency medicinediagnosticmedicationolanzapine
SAhome2012-02-20

Coroner's Finding: WYATT David James and WYATT Jakob James

24y · Male·Blood loss due to multiple stab wounds to chest and multiple incised wounds of n…

A 24-year-old man with schizoaffective disorder and substance abuse killed his 2-year-old son and himself in March 2009. The deceased had been released on licence following a mental impairment finding and was subject to …

psychiatrycorrectional healthsystemcommunicationmethamphetamine
VIC2012-01-31

Finding into death of Roy Gilbert

54y · Male·Head injuries sustained in motor vehicle accident (driver)

A 54-year-old man, Roy Gilbert, died from head injuries sustained when his car struck a horse galloping on the Princes Highway at 4:50 AM in darkness. The horse, Mr Santiago, had escaped while being led from a vehicle on…

systemdelay
SAhome2012-01-23

Coroner's Finding: HAYWARD Robyn Eileen and DURANCE Edwin Raymond

45y · Female·Robyn Eileen Hayward: gunshot wound to the head; Edwin Raymond Durance: gunshot …

This inquest examined two deaths from gunshot wounds in domestic violence context. Robyn Hayward (45 years) was shot by her estranged partner Edwin Durance (62 years), who was subsequently shot by police. Critical failur…

proceduralcommunicationalcohol
VIChome2012-01-20

Finding into death of Patricia Chan

Female·diabetic ketoacidosis

Patricia Chan died on 25 August 2006 from diabetic ketoacidosis following dental extraction four days earlier. She had type 2 diabetes. Her condition deteriorated over two days at home, and her husband Duncan Tang was ch…

dentistrygeneral medicinedelay
WA2012-01-12

Inquest into the Death of Brennan

38y · Male·Exsanguination due to penetration of arm veins

Declan Brennan, a 38-year-old sentenced prisoner at Acacia Prison due for release on 30 April 2008, died by suicide on 27 April 2008 from exsanguination due to penetrating wounds to his arm veins. Brennan had a long-stan…

psychiatrycorrectional healthsystemdelaylithium
NT2012-01-04

Inquest into the death of Barnabas Naroldol

33y · Male·Longstanding atheromatous coronary artery disease with severe stenosis and cardi…

A 33-year-old Aboriginal man died in custody from longstanding atheromatous coronary artery disease with cardiac hypertrophy. On presentation to the prison clinic with non-specific symptoms (headache, throat pain, arm an…

general practiceemergency medicinecommunicationsystemparacetamol
NT2012-01-03

Inquest into the death of Steven Andrew Forbes

37y · Male·acute viral pneumonia secondary to swine flu (H1N1) infection of the lungs, exac…

Steven Andrew Forbes, age 37, died of acute viral pneumonia secondary to H1N1 influenza, complicated by chronic rheumatic heart disease. He died in police/correctional custody following arrest at hospital discharge for a…

emergency medicineinfectious diseasescommunicationsystemdicloxacillin
WAhospital2012

Inquest into the Death of Keogh

38y · Female·Pulmonary Thromboembolism

Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…

general surgeryintensive carecommunicationdelaywarfarin
VIC2012

Finding into death of Murrindindi Fire

Murrindindi bushfire caused by failed electrical conductor between poles 5 and 6…

The Murrindindi fire of 7 February 2009 resulted in 40 deaths and destroyed multiple towns. The fire originated from a failed electrical conductor on power poles 5-6 at Wilhelmina Falls Road, which had inadequate clearan…

systemdelay
WA2012

Inquest into the Death of Christmas Island Tragedy

27y · Female·Immersion (drowning) and injuries from impact with rocky shore and debris in the…

On 15 December 2010, the suspected irregular entry vessel SIEV 221 crashed on the rocky coastline of Christmas Island during the monsoon season in rough seas, resulting in 50 deaths—30 of whom were recovered and 29 ident…

systemdelay
SAcommunity2011-12-22

Coroner's Finding: HYNES Simon Christopher

41y · Male·acute neck compression due to hanging

Simon Christopher Hynes, aged 41, died by hanging between 7 June and 5 July 2007, shortly after discharge from hospital on leave of absence under a Mental Health Act continuing detention order. He had a 20-year history o…

psychiatryforensic medicinedelaycommunication
NSWhospital2011-12-21

Coroner's Finding: Gabrielle Coventry

14y · Female·Neisseria meningitidis infection (meningococcal septicaemia)

A 14-year-old girl presented to Gosford Hospital Emergency Department on 4 December 2007 with high fever (40°C), headache, vomiting, myalgia, and haemodynamic instability (hypotension, tachycardia, tachypnoea)—all signs …

emergency medicinepaediatricsdiagnosticmedicationceftriaxone
NSW2011-12-19

Villawoodfindings redacted

Male·Suicide: hanging (Al-Akabi, Saunders); diving from balcony (Rauluni)

Three immigration detainees died by suicide at Villawood Detention Centre in Sydney within three months in 2010. Josefa Rauluni (Fijian) jumped from a balcony on 20 September after being informed of imminent removal desp…

psychiatrygeneral medicinediagnosticcommunicationmirtazapine
VIChospital2011-12-16

Finding into death of Lorraine Valerie McDonald

75y · Female·hypovolaemic shock from excessive blood loss

Lorraine McDonald, age 75, died from hypovolaemic shock due to massive intraoperative bleeding during an anterior resection for rectosigmoid adenocarcinoma. Critical deficiencies included: no pre-admission clinic assessm…

general surgerycolorectal surgerydiagnosticprocedural

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