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NTcommunity2011-04-08

Inquest into the death of Kieffen Owen Raggett

8y · Male·undetermined

An 8-year-old boy disappeared from Borroloola on 2 October 2007 and was found deceased in a waterhole 2 days later. While initially classified as accidental drowning, the coroner found substantial evidence suggesting fou…

forensic medicinediagnosticsystem
SAhospital2011-04-07

Coroner's Finding: WATKINS Maureen

56y · Female·pulmonary thromboembolism due to left calf deep vein thrombosis

A 56-year-old woman with bipolar disorder died from pulmonary thromboembolism due to left calf deep vein thrombosis while detained under the Mental Health Act in hospital. She presented with seizures and underwent wrist …

general medicinepsychiatrydiagnosticcommunicationdiazepam
SAhome2011-04-07

Coroner's Finding: LEE Troy Thomas and MATTHEWS Scott Leslie

Troy Thomas Lee: acute neck compression due to hanging; Scott Leslie Matthews: m…

Two men died by suicide while on home detention bail awaiting trial. Troy Thomas Lee (38, hanging) and Scott Leslie Matthews (23, mixed drug toxicity from tramadol and alprazolam overdose) both died on their parents' pre…

general practicepsychiatrycommunicationdelaytramadol
QLDhospital2011-04-05

Hoy, Samara Lee

0y · Female·Birth asphyxia due to tight umbilical cord around neck with meconium aspiration

Samara Lea Hoy died shortly after birth from asphyxia caused by a tight umbilical cord around her neck, complicated by meconium aspiration. The coroner identified multiple systemic failures in care. Crucially, admission …

obstetricsmidwiferydiagnosticcommunication
VIC2011-04-04

Finding into death of Wingeel Plains Fire

Fire outbreak caused by sparks and molten metal from defective wagon air brake s…

A freight train (SAMP3P) caused multiple fires along a railway line in rural Victoria on 2 February 2001. Wagon AQQY 4327 had defective air brake blocks that failed to retract properly, causing excessive friction between…

systemdelay
VICcommunity2011-03-30

Finding into death of Justin Ross Pomery

20y · Male·Massive head injuries from motor vehicle accident (bus rollover)

On 16 April 2009, a V-Line passenger coach rolled over on the Princes Highway near Heathmere, Victoria, killing Justin Pomery (20 years), Sabrina Brady (7 months pregnant), and her daughter Madison. Three passengers who …

systemdelay
VIC2011-03-30

Finding into death of Madison Lee Dobie

2y · Female·Massive head injuries sustained in motor vehicle accident (bus rollover)

A V-Line passenger coach rolled over on the Princes Highway near Heathmere, Victoria on 16 April 2009, killing three occupants: Ms Sabrina Brady (7 months pregnant), her 2-year-old daughter Madison, and Mr Justin Pomery.…

systemdelay
VIC2011-03-30

Finding into death of Sabrina Michelle Brady

19y · Female·Mechanical asphyxia due to crush injuries sustained under coach rollover; pregna…

On 16 April 2009, a V-Line coach rolled over on the Princes Highway near Heathmere, Victoria, killing three occupants: Sabrina Brady (19 years, 7 months pregnant), her daughter Madison Dobie, and Justin Pomery. The coach…

systemdelay
SAhospital2011-03-28

Coroner's Finding: ALLAN Vera

81y · Female·Severe cardiogenic shock complicating cardiac surgery

An 81-year-old woman died of severe cardiogenic shock following elective aortic valve replacement complicated by intraoperative haemodynamic instability and inadequate postoperative ICU management. The surgery involved e…

cardiothoracic surgeryanaesthesiamedicationcommunicationadrenaline
VICcommunity2011-03-17

Finding into death of Stuart Judd

39y · Male·Ischaemic heart disease with complete occlusion of the left anterior descending …

Stuart Judd, a 39-year-old Parks Victoria Ranger, died of acute myocardial infarction due to left anterior descending coronary artery occlusion with ruptured plaque. Eight days before death, he presented to GP Dr V. with…

general practicecardiologydiagnosticdelayomeprazole
VIChome2011-03-09

Finding into death of David William Herbert Spence

92y · Male·Electrocution from contact with live energised metal conduit in roof cavity

David William Herbert Spence, 92 years old, died from electrocution while installing coaxial cable in his roof space. His home, constructed in the 1950s-1960s, contained outdated Vulcanized India Rubber (VIR) wiring in p…

occupational and environmental healthsystemdelay
WAcommunity2011-02-28

Inquest into the Death of Collins

0y · Male·cardiac arrhythmia associated with surgically corrected congenital heart disease

Edward Thomas Collins was a 3-month-old neonate with surgically corrected congenital heart disease (Total Anomalous Pulmonary Venous Drainage) who died on 14 January 2007 from cardiac arrhythmia. On 13 January 2007, he p…

emergency medicinegeneral practicediagnosticcommunication
QLD2011-02-23

MacKenzie, Malcolm; Brown, Graham; Wilson, Robert

Unknown·Multiple injuries from motor vehicle collision. Brown and MacKenzie: head-on col…

Three fatal motor vehicle collisions involving shift workers from coal mines in the Bowen Basin. Graham Brown (54) and Senior Constable Malcolm MacKenzie (43) died in a head-on collision on Yeppoon-Rockhampton Road in Oc…

systemdelay
SA2011-02-09

Coroner's Finding: MADELEY Daniel Nicholas

18y · Male·respiratory failure secondary to closed chest trauma

Daniel Madeley, 18-year-old apprentice toolmaker, died from respiratory failure secondary to closed chest trauma after being entangled in a Soviet-era horizontal boring machine at his workplace in June 2004. The machine …

occupational and environmental healthsystemdelay
NThome2011-02-04

Inquest into the death of Emma Jane Claridge

19y · Female·neck compression due to hanging

Emma Jane Claridge, 19, died by hanging at her home on 26 September 2009, nine hours after being granted day leave from the Cowdy Ward psychiatric ward where she was a voluntary patient. She had been admitted following a…

psychiatrycommunicationsystemrisperidone
VIChospital2011

Finding into death of ALYSSA TZE SIM CHAN

Female·Combination of liver failure, blood loss and shock following needle biopsy

Alyssa, a 9-week-old infant, died from hemorrhage following a liver biopsy at Monash Medical Centre. She had persistent jaundice, and biopsy was undertaken to investigate potential biliary atresia. Post-operatively, nurs…

gastroenterologyanaesthesiadiagnosticproceduralphytomenadione
VIChospital2011

Finding into death of PB

40y · Male·carbon monoxide poisoning

A 40-year-old male sex offender on community-based orders died by carbon monoxide poisoning on 24 August 2009, two days after a serious suicide attempt involving his car. He had been assessed at Frankston Hospital ED on …

emergency medicinepsychiatrydiagnosticcommunication
VIC["community", "home"]["2010-03-03", "2010-02-25"]

Finding into death of Bayden Roy Smith

[47, 77]y · ["male", "female"]·["gunshot injury to head (self-inflicted)", "neck compression"]

Two coronial findings are provided. First, Bayden Roy Smith, 47, died by self-inflicted gunshot wound hours after crisis mental health assessment at Broadmeadows Police Station. The CAT team assessed him as low-risk and …

psychiatryemergency medicinediagnosticcommunication
SAhospital2010-12-30

Coroner's Finding: D'AGOSTINO Antonia

59y · Female·sepsis due to faecal peritonitis due to perforation of sigmoid colon complicatin…

A 59-year-old woman died from sepsis due to faecal peritonitis following a bowel perforation during laparoscopic oophorectomy for a benign ovarian cyst. The perforation was repaired during the initial surgery, but the re…

gynaecologygeneral surgerydiagnosticdelaypethidine
NSWhospital2010-12-22

Finding patience,iandonald 970 07

68y · Male·Complications following colon surgery on a background of cirrhosis of the liver;…

Ian Donald Patience, 68, died on 10 June 2007 from complications following colon surgery in the setting of cirrhosis. He underwent right hemicolectomy at Sydney South West Private Hospital on 31 May 2007 for colorectal c…

general surgerygastroenterologydiagnosticcommunicationmorphine

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