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QLDhospital2008-12-15

Van Putten, Patricia

49y · Female·Respiratory failure sequential to ingestion of Glyphosate due to depression and …

Patricia Van Putten, a 49-year-old retired teacher, died by suicide via glyphosate ingestion on 18 February 2006, four days after discharge from psychiatric hospitalization for a serious self-harm attempt (throat lacerat…

psychiatrygeneral practicecommunicationsystemdosulepin
QLDhospital2008-12-15

Harris, Robert

60y · Male·asphyxia sequential to hanging due to depression

Robert Harris, a 60-year-old man with depression, made two suicide attempts within 24 hours. After the first attempt on 27 June 2006, he was discharged from Cairns Base Hospital Emergency Department with a plan to attend…

psychiatryemergency medicinecommunicationdiagnosticfluvoxamine
QLDhome2008-12-11

Fenner, Christine Maria

48y · Female·Unknown

Christine Maria Fenner, aged 48, disappeared from her home on 12 February 1999 and is presumed dead. In the days before her disappearance, she was observed to be in extremely poor health with concerning signs including f…

delaysystem
SA2008-12-03

Coroner's Finding: WHEATON Rowan Scott

18y · Male·neck compression due to hanging

Rowan Wheaton, aged 18, died by hanging at supported accommodation in April 2006. He had Aspergers Syndrome diagnosed at age 4, with escalating behavioural and mental health crises from adolescence. Despite multiple emer…

psychiatryemergency medicinediagnosticcommunicationcitalopram
QLDhospital2008-11-28

McVey, Oliver Steven

67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent clo…

Oliver Steven McVey, a premature twin born at 31 weeks gestation weighing 1036g, died from complications of endotracheal tube re-insertion at 67 days of age. Following successful surgical ligation of a patent ductus arte…

neonatologycardiothoracic surgeryproceduralcommunication
QLD2008-11-24

Willowbank aircraft accident - Colin Hicklin, Barbara McLelland, Nigel O'Gorman, Susanne Williams, Anthony Winter

Crash of light aircraft following partial engine failure after takeoff. Deaths a…

A Cessna 206 aircraft crashed shortly after takeoff at Willowbank, Queensland on 2 January 2006, killing five of seven occupants. The pilot, a relatively inexperienced 22-year-old with minimal skydiving operation experie…

systemdelay
SAaged care2008-11-06

Coroner's Finding: CECERE Rolando

71y · Male·Positional asphyxia

A 71-year-old man with severe dementia died from positional asphyxia when his neck became wedged in a gate at an aged care facility. He had demonstrated multiple escape attempts within days of admission, with staff docum…

geriatric medicinepsychiatrysystemdelay
QLDcommunity2008-11-05

Boyd, Melanie Kate

Female·death by drug toxicity

Melanie Boyd, a teenager, died from drug toxicity at an unsupervised youth party where she consumed illicit drugs, prescription medications, and excessive alcohol. The inquest revealed critical failures in recognising he…

emergency medicinetoxicologydelaycommunicationillicit drugs
NThospital2008-10-29

Inquest into the death of Sandra McRae

57y · Female·acute pulmonary embolism

Sandra McRae, age 57, died from pulmonary embolism on day 13 of hospitalisation following pelvic fractures sustained in a motor vehicle accident. The coroner found the death was potentially preventable due to failure to …

orthopaedic surgeryintensive carediagnosticsystem
SAhospital2008-10-24

Coroner's Finding: DITTMAR Damien Paul

35y · Male·neck compression due to hanging

A 35-year-old man with chronic depression, alcohol dependence and amphetamine abuse was detained at the Queen Elizabeth Hospital Emergency Department on 15 May 2006 after presenting intoxicated with suicidal ideation. He…

psychiatryemergency medicinecommunicationsystemalcohol
QLDhospital2008-10-14

Mathers, John William

26y · Male·Air embolism due to ruptured spleen (surgery) due to motorcycle accident

John Mathers, 26, died from air embolism during emergency surgery following severe motorcycle trauma. A sedan turned across his path; despite heavy braking, he collided and suffered extensive injuries including ruptured …

emergency medicinetrauma surgerycommunicationsystem
QLDhospitalPodcast2008-10-10

Maxfield, Annette

62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum

A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed…

colorectal surgeryanaesthesiadiagnosticproceduralsevoflurane
SAhospital2008-09-19

Coroner's Finding: ALLEN Richard Grant

60y · Male·haemopericardium due to rupture of right ventricle complicating removal of cardi…

Richard Allen, a 60-year-old man with a permanent pacemaker for sick sinus syndrome, died from haemopericardium due to rupture of the right ventricle during pacemaker lead extraction on 2 November 2005. The 14mm perforat…

cardiologyanaesthesiadiagnosticdelaypropofol
QLDhospital2008-09-12

Neville, Elise Susannah

10y · Female·Head injuries due to fall from a bunk bed

Elise Neville, aged 10, fell from a non-compliant bunk bed and sustained a head injury. At her first ED presentation to Caloundra Hospital at 3:25am, Dr D.—a junior house officer 19 hours into a 24-hour shift—failed to p…

emergency medicineneurosurgerydiagnosticcommunicationmannitol
NTcommunity2008-09-01

Inquest into the death of Robert Daly

38y · Male·coronary atherosclerosis

Robert Taylor Daly, a 38-year-old Aboriginal man, died of coronary atherosclerosis with severe coronary artery blockage and pulmonary edema. He collapsed in a drinking area after consuming alcohol while acutely ill with …

emergency medicinecardiologydiagnosticcommunicationcough mixture
NTcommunity2008-09-01

Inquest into the death of Peter Limbunya

78y · Male·pneumonia with dehydration and exposure to heat as contributing factors

Peter Limbunya, a 78-year-old Aboriginal elder, died from pneumonia complicated by dehydration and exposure after being left unattended at a remote airstrip following hospital discharge. He was not accompanied by a requi…

emergency medicinegeneral practicecommunicationsystem
QLDcommunity2008-08-28

Maslen, Samantha Anne

25y · Female·Neck injuries (fracture/dislocation of upper cervical spine with spinal cord inj…

Samantha Maslen, a 25-year-old woman with depression and complex social factors, was killed during a police pursuit following an alleged petrol station theft. She was a front-seat passenger when the driver, a fatigued 17…

systemdiagnostic
SAhospital2008-08-15

Coroner's Finding: EDWARDS Natasha Anne

31y · Female·right cerebellar cerebrovascular accident (cerebellar infarction with obstructiv…

31-year-old woman presented with acute onset headache, dizziness, vomiting, facial numbness and speech difficulties. Initial CT brain showed equivocal left temporal hypodensity. Dr B. diagnosed acute migraine/benign posi…

neurologygeneral medicinediagnosticdelaymetoclopramide
VIChospital2008-08-15

Finding into death of William Grant Keays

Male·Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unas…

William Keays was a neonate born at 37 weeks via emergency caesarean section for fetal distress during labour induction with Syntocinon. He was stillborn with Apgar scores of 0/0/1, requiring 12 minutes of resuscitation …

obstetricsneonatologycommunicationdelayoxytocin
QLD2008-08-14

Greaves, Colin Arthur

26y · Male·Multiple injuries sustained from a fall of 12 metres through an open hatch on Se…

Colin Arthur Greaves, a 26-year-old casual hydroblaster, died after falling 12 metres through an unsecured hatch (Hatch A) on a Settler tank at Queensland Alumina Limited's Gladstone plant. The hatch should have been wel…

occupational and environmental healthemergency medicinesystemcommunication

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