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VIChospital2010-04-16

Finding into death of Kum Yeo Bae

60y · Female·Penetrating injury of the descending thoracic aorta complicating spinal stabiliz…

A 60-year-old woman died from a penetrating injury to the descending thoracic aorta sustained during spinal stabilisation surgery for a T12 burst fracture. During pedicle cannulation, the surgical awl fractured the left …

neurosurgeryanaesthesiacommunicationdelay
WAcommunity2010-04-15

Inquest into the Death of Lynch

20y · Female·food-induced anaphylaxis, likely to peanut allergen

Kylie Lynch, a 20-year-old woman with chronic asthma and a known peanut allergy, died from anaphylaxis on 2 September 2007 in Coral Bay, Western Australia. She consumed desserts at Fin's Café after dining at a nearby hot…

emergency medicinegeneral practicedelaydiagnosticadrenaline
VIChospital2010-04-13

Finding into death of Gary Allan Carrick

45y · Male·Bronchopneumonia

Gary Carrick, a 45-year-old man with Down syndrome and severe progressive cervical myelopathy, died from bronchopneumonia. He experienced rapid functional decline from January 2008, including loss of mobility, incontinen…

neurologypalliative caredelaystaphylex
VICcommunity2010-04-12

Finding into death of Veronica Campbell

23y · Female·complications of ruptured ectopic pregnancy with massive intra-abdominal haemorr…

A 23-year-old woman with a ruptured ectopic pregnancy at a rural hospital required urgent transfer to a tertiary centre. The initial response was classified as routine, and the first ambulance crew arrived late without a…

emergency medicineobstetricscommunicationsystemmorphine
SAcommunity2010-04-01

Coroner's Finding: HALLORAN James Gordon

52y · Male·hypoxic-ischaemic encephalopathy due to cardiac arrest due to unknown aetiology

James Halloran, age 52, collapsed during chiropractic treatment and suffered cardiac arrest of unknown aetiology. He remained unconscious despite resuscitation and died from hypoxic-ischaemic encephalopathy. Initially su…

emergency medicineintensive caredelaycommunication
QLD2010-03-31

Report on Police Pursuits

Motor vehicle crashes during or following police pursuits

This is a coronial policy report synthesizing 10 inquests into deaths during or following police pursuits in Queensland, June 2005–July 2008. Deceased: Peter Ash, Nicole Ash, Matthew Cullen, Joseph Duncan, Caitlin Hanric…

systemcommunicationalcohol
NTcommunity2010-03-30

Inquest into the death of Michael Anthony Hardy and Robert James Roe

Unknown·Michael Anthony Hardy: acute asphyxiation sustained during dog pack attack. Robe…

Two deaths occurred at Hidden Valley Camp in Alice Springs within weeks of each other. Michael Hardy, aged 27, died from asphyxiation during a dog pack attack while severely intoxicated. Robert Roe, aged 47, died from co…

public healthoccupational and environmental healthsystemcommunicationalcohol
QLDcommunity2010-03-25

Howlett, Peter David

44y · Male·acute myocardial ischaemia due to coronary artery occlusion due to thrombosis an…

Peter Howlett, a 44-year-old male, died of acute myocardial infarction on 21 April 2006 after a 54-minute delay in ambulance arrival. His wife called Triple 0 reporting back pain radiating to chest at 7:20 am. Critical c…

emergency medicineparamedicinecommunicationdiagnostic
VIChospital2010-03-24

Finding into death of Adam Michael Francis Fabre

19y · Male·acute bacterial meningitis with secondary cerebritis (meningococcus)

Adam Fabre, a 19-year-old with fever, severe headache, neck pain, muscle pain (10/10), vomiting, tachycardia and blanching rash, presented to Casey Hospital ED at 3:45am on 14 July 2006. Despite expressing clear concern …

emergency medicineinfectious diseasesdiagnosticcommunicationparacetamol/codeine
QLD2010-03-17

Barnes, Roy

47y · Male·Intracerebral haemorrhage secondary to heroin withdrawal in a patient with sever…

Roy Barnes, a 47-year-old man with chronic heroin use, hepatitis C, and severe coronary atherosclerosis, died from an intracerebral haemorrhage while in police custody. He was held in the Southport watch house for 55 hou…

emergency medicineneurologydelaysystemheroin
VIC2010-03-16

Finding into death of Gregory Price

46y · Male·MULTIPLE INJURIES SUSTAINED IN INDUSTRIAL ACCIDENT

Gregory Price, a 46-year-old foreman-carpenter, died when an elevated work platform (EWP/scissor lift) he was operating tipped over during panel installation. A rope had been tied to the EWP's handrail contrary to manufa…

systemcommunication
SAmental health2010-03-11

Coroner's Finding: SHIN Jeong

35y · Female·pulmonary thrombo-emboli

A 35-year-old woman with treatment-resistant schizophrenia detained under Mental Health Act died from pulmonary thromboembolism while an inpatient in a psychiatric ward. In the final days, she reported leg pain and possi…

psychiatryemergency medicinedelayclozapine
QLDcommunity2010-03-11

Shekar, Sridhar

Male·multiple injuries due to personal watercraft accident

Dr S. died in a personal watercraft collision at the Broadwater, Labrador on 28 April 2008. An inexperienced PWC operator with no prior jet-ski experience, he collided with an anchor chain from a moored boat after being …

occupational and environmental healthemergency medicinecommunicationsystem
QLDhome2010-03-05

Child at Mackay

15y · Female·Ligature compression of the neck (hanging)

A 15-year-old Aboriginal girl died by suicide by hanging on 29 November 2007. She had a transient lifestyle with unstable housing, moved frequently between relatives, was not regularly attending school, and engaged in su…

paediatricspsychiatrysystemdelayalcohol
VIChospital2010-03-04

Finding into death of Andrew Clough

37y · Male·Multiple injuries (motor vehicle impact - driver)

A 37-year-old male driver died from multiple injuries sustained in a motor vehicle collision at an intersection with deficient road safety features. The collision occurred in dark, wet conditions on an unfamiliar road. T…

systemdelay
WAhospital2010-03-03

Inquest into the Death of McLevie

38y · Female·Streptococcus Group A Septicaemia (Post Partum-Puerperal Sepsis)

Susannah McLevie, a 38-year-old woman, died on 6 April 2006 from untreated Group A Streptococcal septicaemia (puerperal sepsis) following childbirth at Osborne Park Hospital. She developed fever (38°C) at 3am on 5 April,…

obstetricsmidwiferydiagnosticcommunicationparacetamol/codeine
VIC2010-02-12

Finding into death of Wesley Robert Jennings

42y · Male·incised wound to the neck

Wesley Robert Jennings, a 42-year-old male with long-standing depression, anxiety, hepatitis C and substance use history, died by suicide by incised neck wound whilst on remand in prison. The coroner found no demonstrabl…

psychiatrypsychologycommunicationsystemcitalopram
VIC2010-02-08

Finding into death of Craig Walter Stevens

34y · Male·Hypoxic-ischaemic brain injury caused by hanging

Craig Stevens, aged 34, died from hypoxic-ischaemic brain injury following a suicide by hanging on 17 June 2008. Despite police intervention, critical delays in cutting the ligature around his neck prevented timely resus…

psychiatrygeneral practicesystemdelaysertraline
WAhospital2010-02-04

Inquest into the Death of Hudson

20y · Male·Ligature compression of the neck (hanging)

Allan Kevin Hudson, a 20-year-old male with a history of depression, suicidality, substance abuse and previous sexual trauma, died by hanging on 13 August 2006 at Sir Charles Gairdner Hospital's psychiatric ward D20. He …

psychiatryemergency medicinediagnosticcommunicationcarbamazepine
SAhospital2010-02-04

Coroner's Finding: KRIVITCH Olga

81y · Female·hypovolaemic shock following bleeding from the site of a femoral angiogram

Olga Krivitch, 81-year-old woman, died from hypovolaemic shock caused by bleeding from her femoral angiogram puncture site. She was admitted for ischaemic leg and underwent unsuccessful thrombolytic therapy. Subsequently…

vascular surgeryradiologydiagnosticmedicationheparin

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