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WAcommunity2005-03-11

Inquest into the Deaths of Judith Lesley Ward and Lorraine Melia

Female·Judith Lesley Ward died as a result of Thermal Injury; Lorraine Melia died as a …

Two deaths resulted from a bushfire started on 27 December 2003 near Tenterden, Western Australia, caused by conductor clashing on a Western Power 22kv overhead line. The fire was ignited when the live red phase conducto…

systemdelay
WAhospital2005-03-03

Inquest into the Death of Giovanni Bertoncini

72y · Male·acute gangrene of colon with probable perforation along with bowel obstruction a…

Giovanni Bertoncini, a 72-year-old man with diabetes and cardiac disease, presented to Sir Charles Gairdner Hospital on Christmas Day 2002 with acute abdominal pain and vomiting. Over two days, his condition deteriorated…

emergency medicinegeneral medicinediagnosticdelayparacetamol
QLD2005-02-09

Landue, Shone; Reid, Gary; Doolan, Stanley

Male·smoke inhalation (Landue and Doolan); smoke inhalation and effects of burning (R…

Three residents died in a boarding house fire at Sandgate, Queensland in August 2002. The fire started beneath the elevated timber building where a large quantity of flammable materials (mattresses, paint tins, timber, t…

systemcommunication
WA2005-01-14

Inquest into the Death of Hendrik Jan Groothedde

39y · Male·Ligature compression of the neck (hanging)

Hendrik Jan Groothedde, a 39-year-old remand prisoner at Hakea Prison, died by ligature compression of the neck (hanging) on 31 January 2003. He had been admitted to custody in December 2002 following stabbing an ex-girl…

psychiatrycorrectional healthcommunicationsystemantidepressants
WAcommunity2005-01-11

Inquest into the Death of Tony Martin

25y · Male·Unlawful Homicide by person or persons unknown

Tony Martin was a 25-year-old Aboriginal man placed on probation in September 1994 following minor criminal charges. He was mandated to reside at Gilroyd Pastoral Station under the supervision of William Ryan. On 24 Dece…

systemdelay
NT2004-12-20

Inquest into the death of Valerie Wurramurra

36y · Female·drowning caused by self-inhalation of vomit

Valerie Wurramurra, a 36-year-old Aboriginal woman, drowned after inhaling vomit following head injuries sustained in a boat accident on 13 April 2002 between Groote Eylandt and Bickerton Island. The coroner made an open…

communicationsystem
WA2004-12-14

Inquest into the Death of Damien George Garlett

18y · Male·Ligature compression of the neck (hanging)

Damien George Garlett, an 18-year-old Aboriginal remand prisoner at Hakea Prison, died by ligature compression of the neck (hanging) on 4 April 2003. He had a history of self-harm, drug-induced psychosis, violent offence…

psychiatrypsychologydiagnosticcommunication
SAhospital2004-11-18

Coroner's Finding: PEDDEY Ross Dudley

63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…

A 63-year-old man died from pneumonia complicating anoxic brain injury following a post-operative haemorrhage from the inferior epigastric artery during ileostomy closure surgery. The critical failure was a 2.5-hour dela…

colorectal surgerygeneral surgerydiagnosticdelaywarfarin
SAhome2004-11-18

Coroner's Finding: CUNNINGHAM Tracey-Lee

26y · Female·morphine toxicity complicated terminally by bronchopneumonia

A 26-year-old woman with chronic migraines and depression died from morphine toxicity complicated by aspiration pneumonia. She had a documented history of drug-seeking behaviour, forged prescriptions, and doctor-shopping…

general practiceneurologymedicationdiagnosticmorphine
WAhome2004-11-03

Inquest into the Deaths of Jack Craig Anstey and Ashleigh Fiona Mungur

Immersion (Drowning)

Two children, Jack Craig Anstey (7) and Ashleigh Fiona Mungur (8), drowned on 3 October 2003 when the Jeep Cherokee in which they were passengers was washed from a low-level ford crossing of the Blackwood River on Jalbar…

systemdelayamphetamine
ACTcommunity2004-11-03

Written Decision And Findings Of The Act Chief Coroner In Relation To The Bushfire Events Of December 2001

Bushfire (multiple fire incidents in December 2001)

In December 2001, multiple bushfires affected the Australian Capital Territory, including the significant Stromlo plantation fire. The Chief Coroner inquired into cause and origin, finding many fires were deliberately li…

systemcommunication
WA2004-10-14

Inquest into the Death of Charles Raymond Gamble

30y · Male·Ligature compression of the neck (hanging)

Charles Raymond Gamble died on 6 May 2003 by ligature compression of the neck while in lawful custody in an AIMS transport vehicle travelling from Perth Watch-house to Perth Central Law Courts. He had recently confessed …

communicationsystemmirtazapine
NTPodcast2004-10-01

Inquest into the death of Jade Lange-Loades, Rory Lange-Loades and Nathaniel Rose

8y · Male·Drowning as the result of a motor vehicle accident

Three children drowned following a motor vehicle accident on the Stuart Highway after a grouser plate fell from an inadequately restrained load on a road train, puncturing their vehicle's tyre and causing loss of control…

proceduralsystem
SA2004-10-01

Coroner's Finding: MAGEE Liam

19y · Male·traumatic rupture of the thoracic aorta with bilateral haemothoraces

A 19-year-old experienced motorcycle racer died from traumatic aortic rupture and bilateral haemothoraces after colliding with a concrete wall at 100 km/h at a racing circuit. He lost control at approximately 205 km/h an…

systemdelay
SAcommunity2004-09-10

Coroner's Finding: CORNISH Peter Henry

43y · Male·aspiration of vegetable matter with occlusion of the upper airway

Peter Cornish, a 43-year-old man with a 17-year history of bipolar disorder, died on 25 September 2001 from aspiration of vegetable matter while experiencing a severe manic episode. In the two weeks before his death, mul…

psychiatryemergency medicinediagnosticsystemcannabis
WAhospital2004-08-16

Inquest into the Death of Gregory Andrew Furniss

25y · Male·cerebral craniopharyngioma

Gregory Andrew Furniss, a 25-year-old male with a history of asthma and congenital cataracts, presented to Swan District Hospital on 11 August 2002 with a persistent headache. He was seen by Dr H. (registrar) who diagnos…

emergency medicinegeneral practicediagnosticdelayterbutaline
SA2004-08-06

Coroner's Finding: TURNER Troy Phillip

36y · Male·hanging

Troy Phillip Turner, aged 36, died by hanging in his prison cell on 2 September 2001 while on remand for serious domestic violence-related offences. The coroner identified several preventable failures: (1) Duty Superviso…

psychiatryemergency medicineproceduralsystemfluvoxamine
NThome2004-08-05

Inquest into the death of Stephen Power

35y · Male·left lower lobe pneumonia

Stephen John Power died of left lower lobe pneumonia on 5 September 2003 after two failed emergency calls requesting ambulance assistance. On Thursday 4 September, dispatcher Coralie Holland failed to send an ambulance d…

emergency medicineparamedicinecommunicationsystemflucloxacillin
SAhospital2004-07-20

Coroner's Finding: QUINN Latoya Shelley

12y · Female·raised intracranial pressure due to ventriculo-peritoneal shunt blockage

A 12-year-old girl with congenital hydrocephalus and a ventriculo-peritoneal shunt presented to the ED with severe unrelieved headache after head trauma. An inexperienced junior doctor (6 weeks in role, minimal neurosurg…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
SAcommunity2004-07-16

Coroner's Finding: DINSDALE Cheree Ann and KLINGNER Peter James

20y · Unknown·Traumatic brain damage complicating gunshot wound to the head

Two young adults aged 20 died from gunshot wounds to the head on 29-30 May 2001 in what appears to be a murder-suicide involving Peter Klingner and his girlfriend Cheree Dinsdale. Klingner had paranoid schizophrenia with…

psychiatryemergency medicinediagnosticcommunicationolanzapine

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