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WAhospital2008-07-28

Inquest into the Death of kidner

41y · Male·Head Injury in a Man with Acute Alcohol Intoxication; basal skull fracture with …

Ronald Gregory Kidner, 41, died from a basal skull fracture and severe head trauma on 25 October 2004, four days after falling at a recreation club while acutely intoxicated. He presented to Nickol Bay Hospital with sign…

emergency medicinegeneral medicinediagnosticcommunicationalcohol
WAcommunity2008-07-18

Inquest into the Death of Oombulgurri

Boyd Lyle Scotty Farrer: Ligature compression of the neck (hanging); Esmay Alber…

Five Aboriginal people died in Oombulgurri, a remote East Kimberley community, between March 2005 and April 2006: four by suicide and one in a motor vehicle accident. Boyd Farrer (16), Alicia Rex (15), Paul Mitchell (21)…

systemdelayalcohol
NTcommunity2008-06-13

Inquest into the death of Nicholas Konedaris

26y · Male·multiple injuries sustained in a motor vehicle accident

Nicholas Konedaris, 26, died in a motor vehicle collision on the Stuart Highway near Alice Springs when an oncoming vehicle crossed the centre line and struck his car head-on. The collision was initiated by momentary ina…

systemdelay
SAaged care2008-06-06

Coroner's Finding: MANN Richard Lesley

45y · Male·choking on food

Richard Mann, a 45-year-old man with intellectual disability and psychiatric illness residing in an institutional setting (Strathmont Centre infirmary), died from choking on food. Critical failures in observation and mon…

psychiatrygeneral practicemedicationcommunicationhaloperidol
SAhospital2008-05-23

Coroner's Finding: KROL Riley

0y · Male·hypoxic ischaemic encephalopathy

Riley Krol, a 11-day-old male infant, died from hypoxic ischaemic encephalopathy following emergency caesarean section delivery on 1 March 2005. After artificial rupture of membranes during labour induction, the foetus d…

obstetricsanaesthesiacommunicationsystemcervedil
QLD2008-05-23

Mosby, Phillemon Edward

55y · Male·Drowning following fall into the sea during pilot transfer operations

Phillemon Mosby, a 55-year-old deckhand on the pilot vessel Alert, was lost at sea on 27 October 2004 while transferring a pilot's luggage during vessel-to-vessel operations. He fell from the narrow port side deck while …

occupational and environmental healthemergency medicinesystemcommunication
NTschoolPodcast2008-05-02

Inquest into the death of Aidan Bott

9y · Male·head injury

Nine-year-old Aidan Bott was fatally struck by a falling branch from an African Mahogany tree in the school courtyard on 22 August 2006, sustaining fatal head injuries. The death was preventable through regular tree main…

emergency medicineneurosurgerysystemdelay
QLD2008-05-02

Blinco, Ricky Glenn; Last, Michael Wayne

35y · Male·Last: head injuries sustained in a motorcycle crash; Blinco: multiple injuries s…

Two men died in separate incidents at Black Duck Valley recreational 4WD and motorbike park. Michael Last (35) died attempting a long-distance motorcycle jump while inexperienced; Ricky Blinco (23) died when his 4WD lost…

systemdelay
QLDcommunity2008-04-24

Schibrowski, John Malcolm

Male·injuries sustained in a motor vehicle incident involving excessive speed on a be…

John Malcolm Schibrowski died in a single-vehicle motor vehicle accident on the Burnett Highway near Bouldercombe on 23 November 2003. He was an unrestrained passenger in the rear seat of a Commodore vehicle that left th…

diagnosticsystemalcohol
QLDhome2008-04-10

Bond, Jakai Ryan

0y · Male·Positional asphyxia contributed to by bronchopneumonia and head injuries

Jakai Ryan Bond, a 10-week-old infant, died from positional asphyxia on 25-26 May 2006 while in his father's care. The father fell asleep holding the baby in a lounge chair; the infant was found face down on his father's…

paediatricsforensic medicinedelaycannabis
SAcommunity2008-04-07

Coroner's Finding: WILSON Christopher Stuart

23y · Male·gunshot wounds to the head

A 23-year-old male was fatally shot in the head by a 17-year-old assailant on 28 February 2004. The coroner identified systemic police failures preceding the death that presented opportunities for intervention. Police fa…

systemcommunication
QLD2008-03-17

Waite, Thomas Dion; Huynh, Mieng; Jacobs, James Henry; Gear, James Michael

gunshot wounds; multiple deaths during police interventions with mentally ill in…

Between October 2003 and February 2006, Queensland police shot and killed four young men suffering from severe mental illness during crisis situations. In all four cases, the shootings were legally justified as the offic…

psychiatryemergency medicinediagnosticcommunicationantipsychotic medications
SAcommunity2008-03-14

Coroner's Finding: STEHBENS Jarrod David

23y · Male·injuries sustained in a shark attack

A 23-year-old research assistant died from injuries sustained in a Great White shark attack while conducting a University of Adelaide diving expedition in the Gulf of St Vincent. The inquest examined whether risk assessm…

occupational and environmental healthemergency medicinesystemcommunication
WAcommunity2008-02-25

Inquest into the Death of Kimberley Coronial Report

Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…

This coronial inquiry examined 22 deaths of Aboriginal people in the Kimberley region of Western Australia between 2000 and 2007. Seventeen were self-harm deaths, with four additional accidental deaths and one homicide. …

public healthpsychiatrysystemdelayalcohol
VIC2008-02-20

Finding into death of Georgie Lopiccolo

47y · Female·Neck compression (ligature strangulation)

A 47-year-old woman died by ligature strangulation using pantyhose while in police custody after arrest on outstanding warrants. She had documented mental health issues (depression) and substance abuse history, with a su…

communicationsystem
SAaged care2008-02-04

Coroner's Finding: KEOUGH Thomas Ryan

18y · Male·methadone toxicity

Thomas Ryan Keough, aged 18, died from methadone toxicity at Palm Lodge, a supported residential facility for people with mental illness, in August 2003. His body was not discovered for 48 hours after death. The coroner …

psychiatryaddiction medicineproceduralcommunicationmethadone
NSWcommunity2008-01-24

Coroner's Finding: Vanessa Ann Anderson

16y · Female·Respiratory arrest due to the depressant effect of opiate medication

Vanessa Anderson, 16, suffered a depressed skull fracture from a golf ball strike and was admitted to Royal North Shore Hospital. She died from respiratory arrest due to opioid-induced respiratory depression, which was e…

neurosurgeryanaesthesiamedicationcommunicationoxycodone
QLDPodcast2008-01-16

Wigg, Allan Thomas

44y · Male·Massive brain damage due to multiple skull fractures from crush injuries sustain…

Allan Wigg, aged 44, died on 3 December 2004 when the rear levelling pin securing the work platform of a banana bagging machine failed due to a defective weld. The platform collapsed, ejecting him from the operator's bas…

occupational and environmental healthproceduralsystem
SAcommunity2007-12-18

Coroner's Finding: Wangary Fires Inquest BORLASE, CASTLE, GRIFFITH

54y · Male·Deaths from bushfire (incineration, inhalation of products of combustion, blunt …

A major bushfire on the Lower Eyre Peninsula in South Australia on 10-11 January 2005 killed nine people. The fire originated from a carbonaceous particle emitted from Marco Visic's diesel vehicle exhaust system with def…

communicationsystem
NThospital2007-12-10

Inquest into the death of Ricky Ryder

28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…

A 28-year-old Aboriginal male died from hypovolemic shock following operative exploration of multiple stab wounds to the thigh. The death was preventable. Critical failures included: delayed surgery from Friday to Saturd…

general surgeryorthopaedic surgerydiagnosticsystem

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