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WAhospital2009-09-11

Inquest into the Death of Gordon

1y · Female·pneumonia (staphylococcal pneumonia with bilateral bacterial pneumonia)

Jezelle Lisa Gordon, a 1-year-old child, died of staphylococcal pneumonia on 26 February 2006 in Port Hedland, Western Australia. She presented to Halls Creek Hospital on 25 February with fever, elevated respiratory rate…

general practiceemergency medicinediagnosticdelayparacetamol
QLD2009-09-10

Blee, Jason George Elliott

33y · Male·Pelvic crush injury sustained while working at an underground coal mine

Jason Blee, a 33-year-old experienced miner and trainer at Moranbah North Mine in Queensland, was fatally crushed on 9 April 2007 when a shuttle car pinned him against a rib (wall) in a narrow underground heading. Follow…

occupational and environmental healthemergency medicinesystemdelay
SA2009-09-04

Coroner's Finding: KENNA Pamela Alice

65y · Female·heatstroke

A 65-year-old woman with recent memory decline went for a walk on an extremely hot day (39°C) without water, hat, or money. She became lost due to cognitive deterioration and walked approximately 8 kilometres from the ci…

forensic medicinepublic healthsystemdelay
SAcommunity2009-08-17

Coroner's Finding: TURNER Brian Raymond

59y · Male·ischaemic heart disease due to coronary atherosclerosis

Brian Raymond Turner, 59, died from ischaemic heart disease due to coronary atherosclerosis following an out-of-hospital cardiac arrest in a medical clinic car park. He experienced symptoms of chest discomfort and breath…

cardiologyemergency medicinecommunicationdelay
QLDhospital2009-08-13

Duggan, David John

60y · Male·Hypertensive heart disease with chronic fatty liver as other significant conditi…

David Duggan, a 60-year-old man with hypertensive heart disease and cardiomegaly, was admitted to Caloundra Hospital on 10 January 2007 for management of severe acute back pain caused by a suspected L3/4 disc herniation …

emergency medicinegeneral medicinesystemcommunicationoxycodone
SAhospital2009-07-30

Coroner's Finding: BRUNT Sidney

65y · Male·acute right subdural haematoma

Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…

general practiceemergency medicinemedicationcommunicationwarfarin
QLDcommunity2009-07-17

Hanrick, Caitlyn

13y · Female·Traumatic brain and internal injuries sustained when struck by a motor vehicle d…

Caitlin Hanrick, aged 13, was struck by a stolen vehicle being pursued by police on 4 December 2006 while crossing a pedestrian crossing at Redcliffe State High School. She died from traumatic brain and internal injuries…

communicationsystemcannabis
QLDhospital2009-07-10

Coleman, Randall John

39y · Male·Strychnine toxicity

Randall Coleman, 39, died from strychnine toxicity after deliberately ingesting poison while in custody at Kingaroy watchhouse on 18 January 2007. He had secreted the vial on his person at arrest on 16 January, despite p…

emergency medicinepsychiatrycommunicationdelaystrychnine
QLD2009-07-03

Stanford, Tony John

36y · Male·Hanging

Tony Stanford, a 36-year-old remand prisoner with depression and a history of suicide attempt, died by hanging in his cell at Arthur Gorrie Correctional Centre on 19 September 2006. He was on a risk management plan requi…

psychiatrypsychologysystemcommunication
SAcommunity2009-06-30

Coroner's Finding: SALAGARAS Steven

56y · Male·effects of heat exhaustion

Steven Salagaras, a 56-year-old charity collector, died from heat exhaustion on 22 January 2006 after working in extreme heat (40.8°C) during a heatwave. He was observed appearing physically distressed while collecting d…

occupational and environmental healthforensic medicinesystemdelay
VIChome2009-06-29

Finding into death of Leigh Sarah Sinclair

25y · Female·effects of fire / inhalation of fire fumes

Two young people died in a preventable building fire at an unregistered rooming house in Brunswick, Victoria. The fire started from faulty electrical wiring in the pizza restaurant ceiling below their bedroom. Multiple s…

systemcommunicationalcohol
SAaged care2009-06-26

Coroner's Finding: DAVIES Harold Leslie

87y · Male·multi organ failure due to septic shock complicating urinary tract infection and…

An 87-year-old man with atrial fibrillation on warfarin developed septic shock and multi-organ failure following traumatic bladder catheterisation. Two catheterisation attempts occurred on 15 July 2005: an unsuccessful a…

general practiceurologyproceduralcommunicationwarfarin
QLDhome2009-06-19

Nielsen, Shane Robert

33y · Male·Gunshot wound to the head (manner of death remains open: suicide or homicide can…

Shane Nielsen, a 33-year-old man associated with outlaw motorcycle gangs, was found deceased with a gunshot wound to the head on 1 January 2006. Police concluded suicide within 30 minutes without adequate investigation. …

forensic medicinediagnosticsystemamphetamine
NSWhospital2009-06-12

Coroner's Finding: Rebecca Murray

29y · Female·Multisystem organ failure following postpartum haemorrhage due to atonic uterus

Rebecca Murray, 29, died from multisystem organ failure following postpartum haemorrhage after an emergency caesarean section at Bathurst Base Hospital on 24–25 June 2007. The coroner found her death preventable. Key cli…

obstetricsanaesthesiasystemcommunicationoxytocin
WA2009-06-12

Inquest into the Death of Ward

46y · Male·Heatstroke

Ian Ward, a 46-year-old Aboriginal man, died from heatstroke on 27 January 2008 while in custody, transported by GSL Custodial Services in a Mazda E2500 prisoner van from Laverton to Kalgoorlie. The rear pod in which he …

systemdelay
NTcommunity2009-06-10

Inquest into the death of Robert Plasto-Lehner and David Gurralpa aka Moscow

Male·David Gurralpa: sudden heart attack (coronary atherosclerosis with long-standing…

Two deaths resulted from police restraint in prone positions. David Gurralpa, a 39-year-old Aboriginal man with pre-existing coronary artery disease, died of sudden cardiac arrest following police restraint during a dome…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
NTcommunity2009-06-04

Inquest into the death of Kunmanara Forbes

15y · Female·Hanging (self-inflicted)

A 15-year-old Aboriginal girl in a remote Central Australian community died by suicide following a year marked by petrol sniffing, sexual abuse concerns, and reported suicide attempts. She suffered multiple sexually tran…

paediatricspsychiatrycommunicationsystem
VIChome2009-06-02

Finding into death of Mark Andrew Downie

32y · Male·overdose of a combination of chlorpromazine, mirtazapine, and diazepam

Mark Downie, aged 32, died from an overdose of chlorpromazine, mirtazapine, and diazepam at home on 16 January 2007, eleven days after discharge from psychiatric hospital. He had a history of depression, polysubstance ab…

psychiatrysystemdelaychlorpromazine
QLD2009-06-01

Downing, Cheyenne Ruby

2y · Female·Asphyxial death associated with drowning

Cheyenne Ruby Downing, aged 2 years, drowned in a school swimming pool after accessing it through an inadequately secured gate created by her father in the boundary fence between their rental home and Peace Lutheran Coll…

systemcommunication
SAhospital2009-05-22

Coroner's Finding: ROBERTS Jarrad Delroy

10y · Male·sepsis (fusobacterium necrophorum) complicating right otitis media

Jarrad Roberts, a 10-year-old with learning disabilities and likely ADHD, died from sepsis due to untreated right otitis media caused by Fusobacterium necrophorum. He had been acutely ill for 5-7 days before finally seei…

paediatricsgeneral practicedelaysystemamoxicillin

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