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SAhospital2010-09-27

Coroner's Finding: ORMEROD Madison Hayley

4y · Female·consequences of incarcerated congenital left diaphragmatic hernia

Madison Ormerod, aged 4 years, died from incarcerated congenital left diaphragmatic hernia. Over 3 months before death, she presented with persistent vomiting and abdominal pain to her GP and paediatrician. The paediatri…

general practicepaediatricsdiagnosticdelay
SAcommunity2010-09-27

Coroner's Finding: DALY Michael Barry

53y · Male·Burns to 75% of body surface area and severe lower airway inhalation injury

Barry Michael Daly, 53, died from severe burns (75% BSA) and inhalation injury sustained in a deliberately-set house fire on 20 April 2008. He had been detained at Glenside Hospital on 10 April 2008 under the Mental Heal…

psychiatryemergency medicinecommunicationsystem
VICcommunity2010-09-20

Finding into death of Jesse Lee McGann

19y · Male·Hypoxic brain injury due to aspiration of food bolus

Jesse Lee McGann, a 19-year-old with severe autism, Asperger's syndrome, and documented swallowing difficulties, died from hypoxic brain injury caused by aspiration of a food bolus while in disability respite care. Criti…

emergency medicineintensive caresystemcommunication
VICmental health2010-09-16

Finding into death of Louise Litis

37y · Female·Hypoxic brain injury consequent upon hanging

Louise Litis, 37, died from hypoxic brain injury following a hanging at Northpark Private Hospital's Mother and Baby Unit on 7 December 2007. She had severe recurrent postpartum depression and had attempted suicide two w…

psychiatryintensive carediagnosticcommunicationsertraline
VICaged care2010-09-08

Finding into death of Joan Hendrickson

78y · Female·Aspiration pneumonia, epistaxis, and trauma to the face

Joan Hendrickson, a 78-year-old with vascular dementia, was assaulted by a co-resident at an aged care facility in April 2006, sustaining facial trauma and epistaxis. She died from aspiration pneumonia 10 days later. The…

general practicegeriatric medicinecommunicationsystem
QLDcommunity2010-09-07

Simpson-Willson, John Douglas

56y · Male·head injuries inflicted by blunt force trauma

56-year-old John Douglas Simpson-Willson was fatally assaulted in Brisbane's Botanical Gardens on 3 June 2005 by Daniel Pattel, released from prison five days earlier. Pattel had expressed clear intentions to kill someon…

psychiatrycorrectional healthdiagnosticcommunication
NSWhospital2010-09-03

Woodcock 2011 06 14 12 49 10 862

Male·Myocardial failure resulting from excessive pulmonary blood flow and consequenti…

One-month-old Liam Woodcock, born extremely prematurely at 27.5 weeks gestation weighing approximately 1 kilogram, died from myocardial failure secondary to excessive pulmonary blood flow in the context of severe congeni…

neonatologyintensive caremedicationproceduralpropofol
NSW2010-09-03

Speering monica trent findings

40y · Male·Self-inflicted gunshot wound to the head

Trent Speering, a 40-year-old NSW paramedic, shot and killed his mother Monica, then shot himself on 11 June 2008. The coroner found that Trent suffered untreated paranoid personality disorder and depression. Despite mul…

psychiatrypsychologydiagnosticcommunication
QLD2010-08-31

Muir, Jason Andrew

36y · Male·Effects of hanging

Jason Muir, a 36-year-old remand prisoner with a history of mental illness and suicidal ideation, died by hanging in Arthur Gorrie Correctional Centre. He had been removed from suicide observation in June 2008 following …

psychiatrycorrectional healthsystemdelayquetiapine
VICaged care2010-08-28

Finding into death of Patricia Mary Cook

85y · Female·Complications of subdural haematoma (evacuated), secondary to fall, contributed …

Patricia Cook, 85, died from complications of a subdural haematoma following a fall at a supported residential service (SRS) while on warfarin for atrial fibrillation. She fell on 30 September 2007, striking her head. Pe…

geriatric medicineneurosurgerycommunicationsystemwarfarin
QLD2010-08-27

Clumpoint, Thomas Andrew

40y · Male·Laryngeal stenosis caused by laryngeal oedema due to squamous cell carcinoma of …

Thomas Andrew Clumpoint, 40-year-old Aboriginal man, died from laryngeal stenosis caused by squamous cell carcinoma of the head and neck while imprisoned. He had undergone surgery and chemo-radiation for tonsillar cancer…

ENT surgeryradiation oncologycommunicationsystemmorphine
NSWhome2010-08-26

Coroner's Finding: Kate Therese Bugmy

26y · Female·Streptococcal Sepsis resulting from Skin Ulceration and complications of Cerebra…

Kate Therese Bugmy, a 26-year-old woman with cerebral palsy, epilepsy, and intellectual disability, died on 28 June 2007 of Streptococcal sepsis from infected pressure ulcers. She was cared for at home by her mother Daph…

general medicineemergency medicinesystemcommunication
VIC2010-08-23

Finding into death of Japanese Screens and Interiors Fire

Exothermic chemical reaction and spontaneous combustion of nitrocellulose-based …

A firefighter was critically injured in a fire caused by exothermic chemical reaction of nitrocellulose-based lacquer overspray in a furniture spray booth. Poor housekeeping, accumulation of flammable dust, removal of ex…

systemcommunication
VIChome2010-08-23

Finding into death of PC

20y · Male·pulmonary oedema due to acute on chronic heart failure resulting from dothiepin …

A 20-year-old man died from pulmonary oedema due to acute-on-chronic heart failure resulting from dothiepin overdose. He had complex mental health and substance use issues dating back to age 16. He was prescribed dothiep…

general practicepsychiatrydiagnosticmedicationdosulepin
SAcommunity2010-08-12

Coroner's Finding: BAIS Ricky James

38y · Male·ischaemic heart disease

Ricky James Bais, a 38-year-old man with paranoid schizophrenia and undiagnosed 75% left anterior descending coronary artery narrowing, died during police restraint. He had absconded from mental health detention at Noarl…

psychiatrygeneral practicesystemcommunicationdepot zuclopenthixol
VICcommunity2010-08-06

Finding into death of Lauren Katherine James

26y · Female·Complications of liposuction surgery: sepsis, decreased respiratory function sec…

Lauren James, a 26-year-old woman, died from complications of elective liposuction surgery performed on 19 January 2007. She presented to the clinic on 22 January with severe pain and asymmetrical swelling of her left th…

plastic and reconstructive surgerygeneral practicediagnosticcommunicationpethidine
VIC2010-08-05

Finding into death of Jenifer Elliott

Female·injuries sustained in an explosion

A 38-foot Halvorsen motor cruiser (Leda II) exploded at a refuelling wharf in May 2008, killing Jennifer and Alexander Elliott. The explosion resulted from petrol vapour accumulation in the bilge, ignited when the port e…

communicationsystem
VIC2010-08-03

Finding into death of Drew William Ritchie

14y · Male·Multiple injuries sustained in a motor vehicle collision (passenger)

Five Victorians died in a motor vehicle collision on the Cairo-Alexandria Road in Egypt when a tour bus ran off the roadway after passing through a left-hand bend. The driver lost control of the bus travelling at approxi…

systemdelay
VIC2010-08-03

Finding into death of George Panayiotis

48y · Male·Multiple injuries sustained in a motor vehicle collision (passenger)

Five Victorians died on 10 January 2006 when their tour bus ran off the Cairo-Alexandria Road in Egypt after a day trip. The driver lost control on a wet, poorly-lit highway with an imperfect road surface. While multiple…

systemdelay
WAcommunity2010-07-30

Inquest into the Death of Dingle

34y · Female·complications of metastatic rectal cancer

Penelope Dingle died of metastatic rectal cancer on 25 August 2005. She was diagnosed with localised rectal cancer in February 2003 when a potential surgical cure was possible. However, she rejected mainstream treatment …

colorectal surgerygeneral practicediagnosticcommunication

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