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QLDhospital2011-06-29

Heidrich, Bela

0y · Female·Mechanical asphyxia due to or as a consequence of overlaying while bed-sharing d…

Bela Heidrich, a newborn, died from mechanical asphyxia due to overlaying while bed-sharing with her mother during breastfeeding in hospital. The mother, Zelia, was exhausted after labour and fell asleep while breastfeed…

midwiferyobstetricscommunicationsupervisionpethidine
QLDhospital2011-06-24

(C) a 15 month old child

1y · Male·Complication of burns and trauma to the mesenteric artery

A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unk…

paediatricsplastic and reconstructive surgerycommunicationsystemrisperidone
NSWmental health2011-06-23

Djordevic final

32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …

A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…

obstetricsgeneral practicecommunicationsystemclozapine
SAhospital2011-06-22

Coroner's Finding: TRENGROVE Ian

81y · Male·Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with co…

An 81-year-old man died from retropubic and retroperitoneal haemorrhage complicating pelvic fractures sustained in a fall at church. He was on warfarin for atrial fibrillation with an excessive INR of 4.6 at the time of …

emergency medicinegeneral medicinediagnosticcommunicationwarfarin
VIChospital2011-06-16

Finding into death of Owen Appleby

0y · Male·Hypovolemic shock, metabolic acidosis and coagulopathy in association with subga…

Owen Appleby, born at Portland Hospital after labour induction, developed hypovolemic shock and died at Warrnambool Hospital 17 hours after birth. Ventouse extraction was used to assist delivery; he was born with low APG…

obstetricsneonatologydiagnosticdelayprostin gel
QLDhospital2011-06-10

Conlan, Kathleen Anne

70y · Female·Cardiac arrest caused by a combination of gastric haemorrhage and pneumonia exac…

Mrs Kathleen Anne Conlan, 70, died from cardiac arrest caused by gastric haemorrhage and pneumonia on a background of coronary artery disease. She presented with severe epigastric pain and was appropriately admitted for …

emergency medicinesurgerydelaymorphine
QLDhospital2011-06-09

Tranby, James Errol

64y · Male·necrotising fasciitis precipitated by a fishbone perforating his rectum, leading…

James Tranby, a 64-year-old Indigenous diabetic prisoner, presented with a fish bone lodged in his rectum on 3 December 2008. Following removal on 5 December, he developed progressive sepsis leading to necrotising fascii…

general surgerycolorectal surgerydiagnosticdelayinsulin
SA2011-06-08

Coroner's Finding: MORRIS Julia Hisae and JAST Raymond Glen

Unknown·Gunshot wound to the head (self-inflicted)

Two suicides occurred at a commercial firing range where individuals gained easy access to firearms. Julia Morris, 23, with documented borderline personality disorder and recent suicide attempt, was discharged from hospi…

psychiatryemergency medicinesystemcommunication
VIChospital2011-06-07

Finding into death of Angelo Lombardo

46y · Male·Coronary artery atherosclerosis

Angelo Lombardo, 45-year-old with schizophrenia, was detained by police under Mental Health Act and brought to ED after acute behavioural disturbance. He received 6mg clonazepam and 20mg olanzapine IM in the ambulance ba…

emergency medicinepsychiatrymedicationsystemclonazepam
NSWaged care2011-05-20

Coroner's Finding: Iris Conyngham

91y · Female·traumatic subarachnoid haemorrhage and acute and chronic subdural haematoma as a…

91-year-old admitted to high-care aged care facility (Bennelong House) on 14 October 2009 following stroke and multiple falls. Within one hour of arrival, she fell from bed and lay on the floor for approximately 45 minut…

geriatric medicineproceduralcommunication
VICaged care2011-05-20

Finding into death of Lena Divola

59y · Female·Subdural haemorrhage from blunt force trauma to head sustained in a backwards fa…

Lena Divola, a 59-year-old woman with intellectual disability, schizophrenia, and depression living in supported accommodation, sustained a head injury on 24 December 2007 when she fell backwards from a walker being push…

general practicepsychiatryproceduralcommunicationwarfarin
VIChospital2011-05-18

Finding into death of Hannah Paige Pain Fowler

11y · Female·Sepsis due to acute peritonitis secondary to perforated gangrenous acute appendi…

Hannah Fowler, aged 11, died from sepsis secondary to perforated gangrenous acute appendicitis. She presented with progressive abdominal pain, vomiting, anorexia and malaise over four days before sudden deterioration and…

paediatricsemergency medicinediagnosticdelayparacetamol
VICcommunity2011-05-16

Finding into death of Aaron

14y · Male·injuries sustained in fall from height

Aaron, aged 14, died by suicide from a fall from an 11th-floor balcony. Over 12 years, he had 14 child protection notifications for exposure to domestic violence, neglect, parental substance misuse, poor school attendanc…

paediatricspsychiatrydiagnosticsystem
WAhospital2011-05-12

Inquest into the Death of Walden

68y · Female·Multi-organ failure associated with septic shock following duodenal perforation …

Athenia Hana Walden, 68, died from multi-organ failure and septic shock following duodenal perforation during laparoscopic surgery at Swan District Hospital on 8 May 2008. Surgery was performed to remove her gallbladder,…

general surgerygeneral practicediagnosticcommunicationpethidine
SAcommunity2011-05-06

Coroner's Finding: RAPHAEL Daniel Buddy

20y · Male·closed head injury

A 20-year-old man on a stationary scooter was struck from behind by a van while waiting to turn right at a traffic junction in poor visibility. The driver was monocular (one eye only) due to diabetic complications and fa…

ophthalmologyoccupational and environmental healthdiagnosticsystem
VIChospital2011-05-04

Finding into death of Ms P

30y · Female·Multi organ failure from hydrochloric acid ingestion

Ms P, a 30-year-old woman with recent-onset depression and anxiety, died from multi-organ failure following intentional hydrochloric acid ingestion on 22 September 2008. She had presented to mental health services on 18 …

psychiatrygeneral practicecommunicationsystemtemazepam
ACThome2011-04-29

Inquest Into The Death Of Yvette Allison Havet

33y · Female·heroin toxicity

Yvette Havet, a 33-year-old woman recovering from alcohol and drug addiction, died of heroin toxicity in May 2007. The coroner found that her fiancé administered the lethal injection, though she had also consumed substan…

toxicologyemergency medicinedelayheroin
WAhome2011-04-21

Inquest into the Death of Whitehouse

3y · Male·unascertainable; malnourishment was a significant contributing factor

Bradley Frederick Whitehouse, aged 3 months, died on 10 February 2008 from causes ruled unascertainable. He was severely malnourished and emaciated at death, having deteriorated dramatically over the final month of life.…

paediatricsgeneral practicecommunicationdelaymethamphetamine
VICcommunity2011-04-20

Finding into death of Liangwei Wang

43y · Male·Drowning

Liangwei Wang, a 43-year-old Chinese national, drowned after being swept from rocks while rock fishing at Potters Hill Road, San Remo in December 2009. He was washed off by an unexpectedly large wave and made unsuccessfu…

systemdelay
VICaged care2011-04-14

Finding into death of Anderina Laura Sanderson

89y · Female·Ischaemic heart disease in a woman with a history of recent assault

Mrs Anderina Sanderson, 89, died from ischaemic heart disease four days after being assaulted by a male resident with dementia in an aged care facility. The forensic pathologist concluded the assault accelerated her decl…

geriatric medicinepsychiatrysystemcommunicationparacetamol/codeine

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