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VICcommunity2010-01-20

Finding into death of Jennifer Gibbins

54y · Female·Sepsis due to bronchopneumonia complicating malignant spindle cell tumour of rig…

Jennifer Gibbins, a 54-year-old woman with non-verbal communication disability living in supported accommodation, presented with recurrent cough from April 2005. Initial management consisted of antibiotics prescribed by …

general practicerespiratory medicinediagnosticdelayantibiotics
NThome2010-01-19

Inquest into the death of Deborah Leanne Melville

12y · Female·acute septicaemia resulting from osteomyelitis of the left femur

A 12-year-old Aboriginal girl died from septicaemia caused by untreated osteomyelitis of the left femur. Three weeks after a sports injury, despite evidence of severe and deteriorating illness including inability to walk…

orthopaedic surgeryinfectious diseasesdiagnosticsystem
NTcommunity2010-01-19

Inquest into the death of Baby Kalib (Child 7)

0y · Male·failure to thrive due to insufficient caloric intake

Kalib died from failure to thrive due to insufficient caloric intake at 7 weeks old. He was born to a mother with a documented history of severe neglect and physical abuse of multiple children over 5 years, during which …

paediatricsgeneral practicesystemcommunication
VIChospital2010-01-15

Finding into death of Josephine Cesnik

76y · Female·complications of subdural haemorrhage (operation)

Josephine Cesnik, 76, died from complications of subdural haemorrhage following head trauma on 20 January 2008. She initially concealed the injury, attributing it to a fall, and did not seek medical attention for 9 days …

emergency medicineneurosurgerydelaywarfarin
VIC2010-01-14

Finding into death of Sharkia Handy

14y · Female·hanging

Sharkia Handy, a 14-year-old girl in out-of-home care, died by hanging in December 2007. She had significant unaddressed mental health concerns including suicidal ideation, self-harm, and grief following peer suicides. T…

paediatricspsychiatrycommunicationsystem
WAhospital2010-01

Inquest into the Death of West

8y · Male·Hypoxic Ischaemic Encephalopathy resulting from asphyxiation due to co-sleeping …

Nathaniel West, an 8-day-old Aboriginal newborn, died from hypoxic ischaemic encephalopathy following accidental asphyxiation due to co-sleeping (bed-sharing) with his mother at Kalgoorlie Regional Hospital on 4 May 2006…

neonatologyintensive caresystemcommunicationmetronidazole
VIChospital2010

Finding into death of Nicole Joy Millar

42y · Female·Complications of cutaneous burns

Nicole Joy Millar, 42, died from severe burns inflicted by her intimate partner in a premeditated attack at a petrol station. She had disclosed prior intimate partner violence to support services but remained isolated an…

emergency medicineplastic and reconstructive surgerycommunicationsystemdiazepam
QLDmental health2009-12-16

Shishko, Peter

47y · Male·abnormal heart rhythm (arrhythmia) induced by atherosclerosis, occurring in the …

Peter Shishko, a 47-year-old man with bipolar affective disorder, died in a mental health facility while in involuntary detention. He suffered a fatal cardiac arrhythmia on a background of severe coronary atherosclerosis…

psychiatrycardiologydiagnosticsystemdiazepam
SAmental health2009-12-04

Coroner's Finding: BLUNDEN Peter Ross

54y · Male·hanging by ligature

Peter Ross Blunden, a 54-year-old man with chronic schizophrenia detained under the Mental Health Act, died by hanging in the shower room of Cramond Clinic open ward. He had expressed suicidal ideation throughout his adm…

psychiatryemergency medicinecommunicationsystemoxazepam
NThospital2009-12-02

Inquest into the death of Matthew Winsloe Hinton

18y · Male·acute multiple drug toxicity

Matthew Hinton, an 18-year-old male, died from acute multiple drug toxicity after consuming nine LSD tablets and methamphetamine. Police attended at approximately 5:30am when called to a disturbance, but a critical delay…

emergency medicineintensive carecommunicationsystemLSD
NTcommunity2009-11-27

Inquest into the death of Jaron Mamarika, Dwayne Bara, Jaross Amagula and Francene Huddleston

Unknown·Multiple blunt injuries sustained in motor vehicle accident (primary causes: Jar…

Four young Aboriginal people died following a motor vehicle accident on a remote unsealed road. The driver, who was unlicensed and inexperienced with significant neuromuscular conditions affecting motor control, was trav…

diagnosticsystem
SAhospital2009-11-25

Coroner's Finding: WILMAN Joyce Millicent (aka Bracegirdle)

62y · Female·gastric necrosis and perforation due to strangulated diaphragmatic hernia

Joyce Wilman, 62, died from gastric necrosis and perforation due to strangulated para-oesophageal hernia whilst detained under Mental Health Act at Queen Elizabeth Hospital. She presented with vomiting and abdominal pain…

psychiatrygastroenterologydiagnosticcommunication
QLDhome2009-10-16

Anderson, Andrew Scott

14y · Male·gunshot wound to the head

Andrew Scott Anderson was a 14-year-old boy placed in Department of Child Safety care following his father's physical assault. He had a longstanding history of behavioral difficulties, ADHD, depression, and substance use…

psychiatrypaediatricsdiagnosticcommunicationmarijuana
QLDcommunity2009-10-06

Irwin, Brett Andrew and Semyraha, Craig Anthony

Male·Constable Irwin: gunshot wound entering left upper quadrant of back, perforating…

This inquest examined the deaths of Constable Brett Irwin and Craig Semyraha during a police warrant execution in July 2007. Constable Irwin was fatally shot by Semyraha during an attempted arrest at night. Critical clin…

systemcommunicationamphetamine
SApsychiatric ward2009-10-01

Coroner's Finding: RODRIGUEZ Antonio

49y · Male·hanging (suicide)

Antonio Rodriguez, aged 49, died by hanging on 16 September 2006, two hours after discharge from Ward B8 (psychiatric short-stay unit) at Royal Adelaide Hospital. He had been admitted with severe depression and active su…

psychiatrydiagnosticcommunicationolanzapine
QLDaged care2009-10-01

Streader, Leon

68y · Male·coronary atherosclerosis worsened by heat stroke

Leon Streader, a 68-year-old man with schizophrenia, epilepsy, obesity, and coronary artery disease, died from coronary atherosclerosis worsened by heat stroke whilst residing in a level-3 accredited hostel on an extreme…

general practicepsychiatrysystemdelaybenztropine
WAhospital2009-09-30

Inquest into the Death of Watmore

17y · Male·fatal asphyxia resulting from severe upper airway obstruction secondary to acute…

Kieran Watmore, a fit 17-year-old male, died from fatal asphyxia at Albany Regional Hospital on 28 August 2008 while being treated for acute tonsillitis. He presented to ED on 27 August with severe throat pain and was pr…

emergency medicinegeneral practicediagnosticcommunicationmorphine
VICcommunity2009-09-29

Finding into death of Christopher Alan Giorgi

24y · Male·Injuries sustained in fire caused by defective electrical wiring in ceiling spac…

A fatal fire in a Brunswick boarding house killed two young residents, Leigh Sinclair (25) and Christopher Giorgi (24), who were unable to escape room 3 due to a locked deadbolt door and the absence of functioning smoke …

diagnosticsystemalcohol
NSWaged care2009-09-25

Finding&recommendation donaldianfairbairn

Unknown·Severe hypoxia due to bilateral pneumonia and severe ischaemic heart disease

Donald Ian Fairbairn, a resident of Yagoona Nursing Home, died at Bankstown Hospital on 23 September 2006 from severe hypoxia due to bilateral pneumonia and severe ischaemic heart disease. The coroner's inquest identifie…

communicationsystem
QLDhome2009-09-21

Zaza, Jean-Marie Jeremie Yannick

2y · Male·Drowning

A 2-year-9-month-old child drowned in a residential swimming pool while in the care of his father, who had fallen asleep indoors. The pool gate's self-closing hinge mechanism had deteriorated over four years without insp…

systemdelay

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