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QLDcommunity2006-06-30

Ioane, Andrew Penetito

17y · Male·Head and chest injuries sustained in a car accident following a police pursuit

Andrew Ioane, aged 17, died when the stolen car he was driving crashed during a 19 km police pursuit lasting 13 minutes through Brisbane suburbs. The pursuit was initiated on suspicion of drink-driving when Ioane stalled…

proceduralcommunication
NTcommunity2006-06-29

Inquest into the death of Clifford Brown

58y · Male·Multiple injuries occasioned in a motor vehicle accident (broken neck, ruptured …

Clifford Brown, an Aboriginal man aged 58, died from multiple injuries sustained in a motor vehicle accident on 18 December 2004 at Barrow Creek, NT. The central clinical issue was the inadequate emergency assessment and…

emergency medicineparamedicinediagnosticcommunication
SAhospital2006-06-22

Coroner's Finding: MERRITT Christopher Simon

24y · Male·0.22 calibre gunshot wound to the head (self-inflicted)

Christopher Merritt, a 24-year-old man with a history of reactive depression triggered by relationship breakdowns, presented to his GP Dr W. on 30 June 2003 with acute tearfulness, suicidal ideation, and dangerous reckle…

general practiceemergency medicinediagnosticcommunicationcitalopram
SAhospital2006-06-16

Coroner's Finding: SMITH Ian Myles

2y · Male·morphine toxicity

A 2-year-old boy died from morphine toxicity approximately 35 hours after suspected ingestion of up to 7 Kapanol (slow-release morphine) capsules accessed from his father's medication left unguarded in the home. Hospital…

emergency medicinepaediatricssystemdelaymorphine
WAhospital2006-05-31

Inquest into the Death of nilon

67y · Female·Pneumonia (streptococcus pneumoniae) in a woman receiving treatment for carcinom…

Peggy Anne Nilon, 67, died from pneumonia (streptococcus pneumoniae) at St John of God Hospital Bunbury on 25 February 2003. Her small cell lung cancer had achieved remission following chemotherapy and radiotherapy. A cr…

oncologygeneral practicediagnosticcommunicationcisplatin
QLDhome2006-05-26

Petrelis, Andrew Nicholas

25y · Male·opiate toxicity (heroin overdose)

Andrew Nicholas Petrelis, a witness protection program participant, was found dead in his Caloundra apartment on 11 September 1995 from opiate toxicity (heroin overdose). He had relocated from Western Australia to Queens…

forensic medicinetoxicologysystemproceduralheroin
SA2006-05-22

Coroner's Finding: GEORGE Patricia Nina

81y · Female·aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphy…

Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive heart failure. A critical ambulance transfer delay …

psychiatryemergency medicinecommunicationsystemsalbutamol
SAhospital2006-05-19

Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…

77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural ta…

cardiologycardiothoracic surgerydiagnosticproceduralramipril
SAhome2006-05-05

Coroner's Finding: KILEY Carol Anne

55y · Female·Multiple drug toxicity due to combination of alcohol and benzodiazepines (oxazep…

Carol Anne Kiley, a 55-year-old woman with chronic back pain, depression, and likely alcohol dependence, died from multiple drug toxicity involving alcohol, oxazepam (toxic level), temazepam, and promethazine. Her GP, Dr…

general practicepsychiatrymedicationdiagnosticoxazepam
NThospital2006-04-28

Inquest into the death of Zena Stevens

2y · Female·septicaemia

Zena Stevens, a 2.5-year-old Aboriginal girl, died from septicemia at Tennant Creek Hospital on 14 January 2005. She had presented to clinic on 11 January with fever, purulent ears and a recently lanced abscess after rec…

paediatricsemergency medicinediagnosticcommunicationprocaine penicillin
SA2006-04-28

Coroner's Finding: WALKER Darryl Kym

31y · Male·hanging (self-inflicted)

Darryl Walker, a 31-year-old Aboriginal man with chronic schizophrenia and diabetes, died by hanging in Port Lincoln Prison on 2 June 2003. He had been transferred to an isolated management unit (Unit 7) on 1 June after …

psychiatrygeneral practicediagnosticcommunicationchlorpromazine
QLD2006-04-26

Karajic, Scott Meho

Male·Multiple crush injuries to the upper chest and neck sustained in a drilling rig …

Scott Karajic died when a stand of drill collars fell through a stabbing mat and crushed him against a mouse hole on a gas drilling rig at Berwyndale South on 28 February 2003. Despite comprehensive safety policies and a…

systemprocedural
WAhome2006-04-21

Inquest into the Death of Grierson, Lewis, Hancock

39y · Male·Grierson: gunshot wound to chest and abdomen from .30 calibre rifle. Hancock and…

Three men died in related incidents in Western Australia. William Joseph Grierson, 39, was shot with a .30 calibre rifle at Ora Banda on 1 October 2000 following a confrontation between Gypsy Jokers motorcycle club membe…

systemdelay
SAhospital2006-04-21

Coroner's Finding: EDWARDS Ruby Mabel

77y · Female·haemorrhagic diathesis due to warfarin toxicity

Ruby Mabel Edwards, 77, died from haemorrhagic diathesis due to warfarin toxicity after 84 days in a rural hospital. She had a prosthetic aortic valve requiring anticoagulation. INR monitoring was inadequate: no tests fo…

general practicehaematologymedicationdelaywarfarin
QLD2006-04-13

Adams, Michael James

20y · Male·Hanging (wilful murder by Andrew Thomas Kranz)

Michael James Adams, aged 20, died by hanging in prison on 11 September 1997. He was placed in Unit 7B at Sir David Longland Correctional Centre despite documented concerns from medical and correctional staff about his s…

systemdelayheroin
QLD2006-04-07

Meech, Paul Andrew

40y · Male·Asphyxia caused by a seizure resulting from severe alcohol intoxication. Underly…

Paul Meech, a 40-year-old man with bipolar affective disorder, died of asphyxia caused by a seizure from severe alcohol intoxication while in police custody at Hervey Bay watch house. Critical failures occurred: (1) The …

psychiatryemergency medicinediagnosticcommunicationhaloperidol
NTcommunity2006-03-22

Inquest into the death of Dolly Granites

70y · Female·fungal pneumonia as a complication of breast cancer and its treatment

Dolly Granites, a 70-year-old Aboriginal woman, died from fungal pneumonia complicating breast cancer in September 2004. A significant 17-month delay occurred between initial detection of a breast lump in October 2002 an…

general practiceoncologysystemcommunication
NT2006-03-03

Inquest into the death of Muhammad Heri

37y · Male·Coronary Atherosclerosis

Muhammad Heri, a 37-year-old Indonesian fisherman, died from coronary atherosclerosis while detained in Darwin Harbour on 28 April 2005. He had been held on his fishing vessel for 7 days without medical examination follo…

forensic medicineemergency medicinesystemdelay
WA2006-03

Inquest into the Death of Leon John Donaldson

20y · Male·Ligature compression of the neck (hanging)

Leon John Donaldson, a 20-year-old sentenced prisoner with a documented history of self-harm, depression, and suicidal ideation, died by hanging in his cell at Casuarina Prison on 2 September 2004. He had been identified…

psychiatrypsychologysystemcommunicationsodium valproate
SAcommunity2006-02-22

Coroner's Finding: SINCLAIR-SPAAN Christopher James

21y · Male·Closed head injury and retroperitoneal and pelvic haematoma due to fractured pel…

A 21-year-old man died from massive internal bleeding into the pelvis and retroperitoneum following a motor vehicle collision with a stobie pole in rural South Australia. He was trapped for over 2 hours before extricatio…

intensive caretrauma surgerycommunicationsystem

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