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SAhospital2009-05-21

Coroner's Finding: FARKAS Karl Derek

45y · Male·intracerebral haemorrhage caused by rupture of arterial aneurysm

A 45-year-old man with an intracerebral haemorrhage from a ruptured aneurysm presented to an emergency department and general practice on multiple occasions in October 2005 with headache, vomiting, dizziness, and neck st…

emergency medicinegeneral practicediagnosticcommunicationaspirin
QLD2009-05-14

Brasher, Gryphyn David

9y · Male·Hypovolaemic shock due to massive blood loss from ruptured right lung as a resul…

A 9-year-old boy, Gryphyn Brasher, was struck and killed by his father's Ford Explorer that rolled backward down a steep driveway (18.6-23.6% gradient) in Toowoomba, Queensland. The vehicle was parked in Park with the ha…

systemcommunication
QLDaged care2009-05-05

Hoy, Raleigh

41y · Male·Dilated cardiomyopathy

Raleigh Hoy, a 41-year-old man with schizophrenia and autistic spectrum disorder, died of dilated cardiomyopathy at a residential care facility (Tarampa After Care Centre) in Queensland in January 2007. While his mother …

psychiatrygeneral practicecommunicationsystemclozapine
SAhome2009-04-17

Coroner's Finding: PARROTT Jenisha Diandra (aka White)

7y · Female·streptococcus pneumoniae sepsis complicating retropharyngeal abscess

A 7-week-old infant died from streptococcus pneumoniae sepsis complicating retropharyngeal abscess. Three days before death, a report was made to child protection services alleging the father had shaken the infants. A ge…

general practiceemergency medicinediagnosticsystem
NThospital2009-04-09

Inquest into the death of Georgia Rae Tilmouth

0y · Female·Organ failure caused by not receiving enough oxygen during labour (intrapartum h…

Georgia Rae Tilmouth was born at 35 weeks gestation after premature labour and died 13 hours later from perinatal asphyxia due to hypoxia during labour. The coroner found multiple deficiencies in obstetric care contribut…

obstetricsmidwiferydiagnosticcommunicationoxytocin
SAcommunity2009-03-30

Coroner's Finding: DALLING Brian Terrance and SALOTTI Jack William and GRZYWACZ Richard John and SOBEY Brian Leslie

Male·acute myocardial infarction due to coronary artery disease (all four); specific …

Four rural South Australian men (aged 42-76 years) died from acute coronary syndrome in 2004-2006. All presented to country medical practitioners with symptoms suggestive of acute coronary syndrome but were not identifie…

general practiceemergency medicinediagnosticcommunicationaspirin
ACT2009-03-27

Inquest Into The Death Of Tania Pauline Lioulios Nee Chacos

42y · Female·Hypoxic ischemic encephalopathy with antecedent cause being self-caused near mis…

Tania Pauline Lioulios, a 42-year-old psychologist, died from hypoxic ischemic encephalopathy following a self-inflicted hanging in a Corrective Services transport vehicle on 4 July 2008. She had presented to mental heal…

psychiatryemergency medicinediagnosticcommunicationalprazolam
QLDcommunity2009-03-26

Madeo, Niceta Maria

82y · Female·Internal injuries sustained in a motor vehicle crash following a police pursuit

An 82-year-old woman, Niceta Maria Madeo, died from internal injuries sustained when a stolen vehicle being pursued by police lost control and collided with her stationary car in Proserpine's central business district. T…

systemdelay
QLDhospital2009-03-20

Wright, Liam John and Powell, Charles Michael

Male·Multiple injuries due to train over-run (suicide by train)

Two separate suicides by train in July 2006 of young men admitted to Logan Hospital mental health services. Liam Wright (19) was transferred from the secure Acute Observation Area (AOA) to an open ward on 14 July 2006 de…

psychiatryemergency medicinediagnosticcommunicationolanzapine
SAhospital2009-03-18

Coroner's Finding: COX Ricky Glen

17y · Male·refractory status epilepticus caused by either a viral infection, an underlying …

Ricky Cox, a 17-year-old Aboriginal youth in juvenile detention, died from refractory status epilepticus triggered by either viral infection or underlying epilepsy. On 2 February 2006, he became febrile and unwell at Cav…

neurologyemergency medicinesystemcommunicationdicloxacillin
QLDhome2009-03-16

Blake, Melissa Maree

Female·Drowning (suicide)

Melissa Maree Blake died by suicide by drowning on 16 January 2007 while receiving community-based treatment for psychotic depression, which developed following a miscarriage. She was referred to Sunshine Coast Mental He…

psychiatrygeneral practicemedicationcommunicationescitalopram
SAcommunity2009-03-06

Coroner's Finding: BRADFORD Steven Michael

20y · Male·severe blunt head trauma

Steven Bradford, a 20-year-old motorcyclist with a learner's permit, was riding an unregistered Honda CVR 600cc motorcycle illegally at high speed. After speeding on the Lincoln Highway, he was pursued by solo police off…

proceduralsystem
QLDcommunity2009-02-12

Malu Sara vessel - Flora Enosa, Wilfred Baira, Ethena Enosa, Ted Harry, Valerie Saub

Drowning or immersion; the precise medical cause could not be ascertained as onl…

This inquest examined the loss of the Malu Sara, an immigration vessel that disappeared in October 2005 with five people aboard in the Torres Strait. The custom-built vessel had serious design flaws including negative fr…

proceduralcommunication
QLDhospital2009-02-09

Clarke, Jon Edward Norman

22y · Male·multi-organ failure secondary to heatstroke

Jon Edward Norman Clarke, a 22-year-old man with chronic schizophrenia-paranoid type managed with Clozapine 500mg daily plus Solian and Efexor XR, collapsed from heatstroke while working as a trolley boy on 27 January 20…

psychiatryintensive caresystemdelayclozapine
WAhospital2009-02-01

Inquest into the Death of Fox

62y · Male·Acute Gastrointestinal Haemorrhage in association with Acute on Chronic Peptic U…

Kenneth Charles Fox, 62, presented to Fremantle Hospital ED on 12 April 2006 with a gastrointestinal bleed after fainting. He was diagnosed with a massive bleed causing hypovolaemic shock and stabilized with fluid resusc…

emergency medicinegeneral surgerydiagnosticdelayaspirin
QLD2009-01-27

Scholl, Philip Henry

42y · Male·multiple injuries sustained in aircraft crash resulting from port side wing tip …

Philip Scholl, an inexperienced microlight pilot with only 20 hours flight training, died in a crash near Mareeba on 20 October 2005. The aircraft T2-2776 was airworthy unfit due to degraded wing fabric, corroded cables,…

aviation medicineemergency medicinediagnosticsystem
QLD2008-12-24

Trcka, Peter Joseph

54y · Male·Drowning after falling overboard from the Shanendale at Otter Reef

Peter Trcka, an experienced 54-year-old fisherman with an artificial leg and history of alcohol-related seizures, disappeared from a trawler anchored at Otter Reef on 1 March 2006. He was last seen at 4:30am appearing we…

emergency medicineneurologysystemdelay
NThospital2008-12-23

Inquest into the death of Jenissa Ryan

14y · Female·blunt force head injury

A 14-year-old Aboriginal girl with newly diagnosed idiopathic thrombocytopenic purpura (ITP) and critically low platelet count (5,000/mm³) absconded from Alice Springs Hospital on 27 January 2006. Hospital staff failed t…

infectious diseaseshaematologycommunicationsystemintragam
QLDcommunity2008-12-22

Venturato, John Ernest

69y · Male·Severe head injury due to a motor vehicle accident

John Venturato, a 69-year-old man driving on the Bruce Highway in Queensland, collided head-on with a wide load (a house 8.9m wide) being transported north at approximately 5:30am on 6 September 2005. He was killed insta…

communicationsystem
QLDhome2008-12-22

Plint, Hannah Isabella Alyson

2y · Female·Drowning in an above-ground swimming pool

Hannah Plint, a 2½-year-old, died from drowning after accessing an above-ground pool by dragging a chair to the gate and opening it unsupervised. Her mother was inside with a younger sibling. The pool fence and gate sepa…

emergency medicinepaediatricssystemdelay

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