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NSWhospital2010-12-21

Coroner's Finding: Joan Dennison

78y · Female·sepsis and aspiration with metabolic dysfunction as a result of mechanical small…

Joan Dennison, aged 78, was discharged from Shellharbour Hospital emergency department on 16 November 2007 with a misdiagnosis of constipation, despite clinical and imaging features diagnostic of small bowel obstruction …

emergency medicinegeneral surgerydiagnosticcommunicationmetoclopramide
WAcommunity2010-12-21

Inquest into the Death of Njana

24y · Male·left intracerebral haemorrhage and consequential brain bleeding resulting from h…

Hendrick Njana, a 24-year-old Aboriginal male, was assaulted on 27 December 2008 by Shaun Steven Midd at a service station in Broome, suffering a strike to the head causing unconsciousness, kicks to the head with steel-c…

emergency medicineintensive carecommunicationdelayalcohol
WAcommunity2010-12-20

Inquest into the Death of Sweeny

20y · Female·Multiple injuries followed by incineration as a result of single motor vehicle c…

Annemarie Sweeny, a 20-year-old Patient Care Assistant at Narembeen Regional Hospital, died in a single-vehicle motor vehicle collision on 8 November 2008 after completing a night shift. She had worked multiple consecuti…

occupational and environmental healthsystemdelaysertraline
QLDcommunity2010-12-16

Bell, Jennifer Elizabeth

34y · Female·Multiple injuries from pedestrian motor vehicle collision; suicide by stepping i…

Jennifer Bell, a 34-year-old woman with severe postnatal depression, obsessive-compulsive disorder, and borderline personality disorder, died by suicide on 2 October 2007 after stepping into the path of a truck. She had …

psychiatrygeneral practicecommunicationsystemstillnox
VICcommunity2010-12-16

Finding into death of Graeme George Watts

67y · Male·Injuries sustained in motor vehicle collision (driver)

Graeme George Watts, a 67-year-old truck driver, died in a motor vehicle collision on 8 May 2009 when his Scania tipper truck lost braking capacity while descending a steep gradient. The vehicle had been improperly conve…

systemprocedural
NSW2010-12-14

Maryannroberts281 05 finding14december2010

73y · Female·Bacterial endocarditis organism arising from a staphylococcal infection that ent…

Mary Roberts, aged 73, received a 5-year custodial sentence in September 2004. She had complex medical needs: dementia from previous strokes, diabetes requiring insulin monitoring, and Warfarin use. Justice Health provid…

correctional healthgeriatric medicinediagnosticcommunicationwarfarin
NSW2010-12-14

Coroner's Finding: Craig Anthony Behr

Male·Head injury caused by Michael Allan Heatley beating and kicking Craig Anthony Be…

Craig Anthony Behr, an inmate at Long Bay Correctional Complex, was killed on 27 March 2004 when placed in a cell with another inmate, Michael Heatley, despite explicit warnings three days prior from a forensic psycholog…

systemcommunication
NSWhome2010-12-13

Coroner's Finding: Paul Justyn Brauer

64y · Male·Large pulmonary embolus (origin undetermined)

Paul Brauer, 64, died of pulmonary embolus at Leeton District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. The coroner ident…

psychiatrygeneral medicinediagnosticmedicationlactulose
SAhospital2010-12-06

Coroner's Finding: GEORGE Irene Thelma

84y · Female·septicaemia secondary to septic arthritis of the left knee

An 84-year-old woman presented to hospital with acute left knee swelling and pain. Initial assessment at Ashford Hospital ED reasonably excluded septic arthritis based on borderline blood tests and absence of fever, thou…

emergency medicinegeneral medicinediagnosticcommunicationmorphine
NSW2010-12-03

Inquest into the death of Dianne BRIMBLE recommendations

Female·death occurring on cruise ship; circumstances involved drug administration

Dianne Brimble died on a cruise ship in 2002 in circumstances involving drug administration. The inquest, resumed in 2010 for recommendations, identified systemic failures in cruise ship regulation, crime investigation j…

systemdelay
NSW2010-11-30

Inquest into the death of Diane BRIMBLE findings

42y · Female·gamma hydroxybutyrate (GHB) toxicity; cardiorespiratory depression

A 42-year-old woman holidaying on a cruise ship died from gamma hydroxybutyrate (GHB) toxicity. She was unknowingly given GHB by male passengers who subsequently engaged in sexual abuse while she was incapacitated. The s…

emergency medicineforensic medicinecommunicationdelaygamma hydroxybutyrate
SA2010-11-19

Coroner's Finding: PARKER Laura

40y · Female·hypoxic encephalopathy and epilepsy with diffuse fibrillary astrocytoma within t…

Laura Parker, a 40-year-old woman with a long history of epilepsy, borderline personality disorder, and recent seizures, died at the Royal Adelaide Hospital on 16 March 2008 from hypoxic encephalopathy caused by cardiac …

neurologypsychiatrydiagnosticcommunicationvigabatrin
VIChome2010-11-05

Finding into death of Veronica Therese Campbell

38y · Female·complications following a ruptured ectopic pregnancy

Veronica Campbell, age 38, died on 31 December 2008 from complications of a ruptured ectopic pregnancy. She presented to Cobram District Hospital with severe pain and was diagnosed with a possible ectopic pregnancy requi…

emergency medicineobstetricscommunicationdelaymorphine
NThome2010-10-29

Inquest into the death of Kristelle Ruby Mulladad aka Oliver

16y · Female·obstructed breathing and heart arrhythmia secondary to severe obstructive sleep …

A 16-year-old Aboriginal girl with severe obstructive sleep apnoea died unexpectedly in her home one week before scheduled surgery. She had been symptomatic since age 13, but surgery was delayed for four years due to mul…

ENT surgerygeneral practicediagnosticcommunication
SAhospital2010-10-26

Coroner's Finding: HASELGROVE Harvie Frederick

88y · Male·left ventricular failure complicating head and soft tissue injuries

An 88-year-old man died from left ventricular failure complicating head and soft tissue injuries sustained when struck by a truck-trailer combination while riding his motorised gopher across a pedestrian crossing. The co…

systemdelay
VICcommunity2010-10-19

Finding into death of Patrick Tolan

55y · Male·Multiple injuries sustained in a fall

Patrick Tolan, a 55-year-old man with chronic depression, alcohol dependence, and multiple suicide attempts, died from injuries sustained in a fall from a shopping centre sign. He had jumped from a parapet four years ear…

psychiatryorthopaedic surgerydiagnosticcommunicationmirtazapine
NSWhome2010-10-15

Coroner's Finding: Jayden Matthew Lynch

3y · Male·asphyxia secondary to epilepsy

Jayden Lynch, aged 3, died on 15 December 2008 while attending family day care in Yamba, NSW. He had epilepsy managed by a paediatrician with medications (Tegratol, Trileptac) and emergency rectal diazepam. On the day of…

paediatricssystemcommunicationtegratol
NSWcommunity2010-10-15

Coroner's Finding: Charmaine Margaret Dragun

29y · Female·Effects of multiple injuries sustained when she projected herself from the top o…

Charmaine Dragun, a 29-year-old newsreader, died by suicide at The Gap on 2 November 2007. She was diagnosed with depression and treated with escalating doses of antidepressants (Efexor, then Lexapro) by multiple health …

general practicepsychiatrydiagnosticmedicationsertraline
VICcommunity2010-10-11

Finding into death of Scott Peoples

20y · Male·multiple injuries sustained in a motor vehicle accident (cyclist)

A 20-year-old elite cyclist was struck from behind and killed by a motor vehicle driven by a 73-year-old man with previously undiagnosed hemianopia (loss of peripheral vision to the left). The driver had struck another c…

forensic medicineneurologydiagnosticcommunicationwarfarin
QLD2010-10-08

Barker, Jeremy Dylan

27y · Male·Hanging

Jeremy Barker, a 27-year-old man with bipolar disorder, recent suicide attempts, and explicit stated intention to hang himself, was admitted to Arthur Gorrie Correctional Centre's medical unit for observation as an 'at-r…

psychiatrycorrectional healthcommunicationsystemcarbamazepine

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