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VIChospital2023-10-25

Finding into death of Bernice Snell

74y · Female·Cardiac arrest due to pulmonary embolism secondary to deep venous thrombosis

A 74-year-old woman presented to ED with left leg swelling and calf pain. She was triaged as category 4 and seen by a doctor after a 4-hour 24-minute delay due to staff shortages and access block. A D-Dimer test showed e…

emergency medicinevascular surgerydelaysystemenoxaparin
NSWhome2023-10-24

Inquest into the death of AW

2y · Female·effects of fire (smoke inhalation and thermal injury)

AW, a 2-year-old girl with 15a11.2 BP1-BP2 microdeletion syndrome and developmental delays, died on 14 April 2018 in a house fire at her rural NSW home. She died from smoke inhalation and thermal injury. The fire's exact…

paediatricssocial worksystemdelay
VIChospital2023-10-20

Finding into death of Vanessa Li

0y · Female·subgaleal haematoma complicating an obstructed labour

Vanessa Li, a term infant born following obstructed labour, died at four days of age from subgaleal haemorrhage (SGH) with severe hypoxic-ischaemic encephalopathy. Labour was managed by private obstetrician Dr K., who wa…

obstetricsneonatologycommunicationdiagnosticoxytocin
WAhospital2023-10-18

Inquest into the Death of Corazon Contreras KEELEY

71y · Female·complications of metastatic endometrial carcinoma, treated palliatively

Corazon Contreras Keeley, a 71-year-old woman with postmenopausal bleeding, was investigated for possible endometrial cancer. Dr K. performed a hysteroscopy with dilation and curettage (HDC) on 29 November 2019, observin…

gynaecologyoncologydiagnosticcommunication
SAcommunity2023-10-13

Coroner's Finding: Adams, Michael Gerard

62y · Male·cardiac arrest complicating psychotic episode

Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applie…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
VIChome2023-10-12

Finding into death of Amanda Jane Harris

36y · Female·Stab wound to the right chest

Amanda Jane Harris, 36, was fatally stabbed by her intimate partner Daniel Eckersley on 7 July 2018 in Cranbourne North, Victoria. Eckersley was prescribed high-dose tramadol (700-800mg daily) for chronic pain over 22 mo…

general practicepain medicinemedicationcommunicationtramadol
WAaged care2023-10-11

Inquest into the Death of Kathryn PAPANASTASIOU

74y · Female·Fractures of the legs, with terminal palliative care, in an elderly lady with mu…

Ms Papanastasiou, a 74-year-old aged care resident confined to a wheelchair, died from bilateral femoral fractures sustained when she fell from her wheelchair during sudden bus braking. The wheelchair was secured using o…

geriatric medicineorthopaedic surgerysystemprocedural
TASaged care2023-10-10

Coroner's Finding: Rouse, Wayne Victor

68y · Male·Sudden cardiac death due to congestive cardiac failure and chronic obstructive p…

Wayne Victor Rouse, 68, died from sudden cardiac death at a residential aged care facility when CPR was not provided despite his active resuscitation order. Staff incorrectly believed he had a 'do not resuscitate' order …

geriatric medicinecardiologycommunicationsystem
VIChospital2023-10-10

Finding into death of Mary Veronica Morrow

68y · Female·Pulmonary embolism due to deep venous thrombosis secondary to fractured left dis…

Mary Morrow, aged 68, died from pulmonary embolism and deep vein thrombosis following a fractured left ankle sustained in Queensland on 23 June 2021. She received appropriate VTE prophylaxis initially (enoxaparin) but th…

emergency medicineorthopaedic surgerycommunicationsystemenoxaparin
VIChome2023-10-10

Finding into death of Abdurrahman Coskun

53y · Male·Neck compression in the circumstances of hanging

A 53-year-old man with sudden-onset major depression died by hanging after being discharged from acute mental health crisis services. He presented with depressive symptoms, suicidal ideation with vague plans, and failed …

psychiatrygeneral practicecommunicationsystemmirtazapine
VIChospital2023-10-05

Finding into death of Ruby-Lee Gold

28y · Female·Multiple injuries sustained in a fall from height

Ruby-Lee Gold, a 28-year-old with schizoaffective disorder and polysubstance abuse, died from multiple injuries sustained falling from an overpass after absconding from Sunshine Hospital's emergency department. She was r…

psychiatryemergency medicinesystemdelaydiazepam
NSW2023-10-04

Inquest into the death of Melville Schrader

76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…

A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2…

oncologygastroenterologydiagnosticsystempsyllium
QLD2023-10-03

Findings of the inquest into the death of GLT

46y · Male·Methylamphetamine toxicity and coronary atherosclerosis

A 46-year-old man died in police custody following a domestic violence order breach arrest in Rockhampton, Queensland. The death resulted from a combination of methylamphetamine toxicity, significant coronary artery dise…

emergency medicineintensive carediagnosticdelaymethamphetamine
NThome2023-09-22

Inquest into the death of Baby Croker

2y · Female·accidental drowning

A 2-year-old girl drowned in a private backyard pool in Katherine during a social gathering. The gate between the entertaining area and the pool was propped open, allowing free access. Although 13 adults were present, no…

systemcommunication
SAhome2023-09-20

Coroner's Finding: Norman, Colin

66y · Male·unascertained (differential diagnosis: chronic alcoholism with alcohol withdrawa…

Colin Norman, a 66-year-old man with significant disability from traumatic brain injury, chronic alcoholism and liver cirrhosis, died at home after failing to receive essential disability support services over a weekend.…

geriatric medicinesystemcommunication
SAmental health2023-09-20

Coroner's Finding: Chessell, David Edward

43y · Male·compression of the neck due to hanging

A 43-year-old male veteran died by hanging in a psychiatric inpatient unit while under a Level 2 Inpatient Treatment Order. He was admitted after a high-lethality suicide attempt involving overdose and carbon monoxide ex…

psychiatryemergency medicinesystemcommunicationmirtazapine
VICcommunity2023-09-18

Finding into death of Meeram Bano

2y · Female·Hypoxic ischaemic encephalopathy in the setting of immersion

Meeram Bano, aged 2 years, died from hypoxic ischaemic encephalopathy following immersion in a pond at Footscray Park on 27 December 2021. She was declared dead on 30 December 2021. While under adult supervision at a fam…

intensive careemergency medicinesystemdelaymidazolam
VICcommunity2023-09-18

Finding into death of Refan Abdulrhman M Al Moarfeg

3y · Female·Hypoxic ischaemic brain injury due to drowning

A 3-year-old girl died from hypoxic ischaemic brain injury following drowning in a pond at Footscray Park. She exited an unsecured playground gate with an inoperable latch mechanism and accessed an unfenced pond masked b…

systemdelayfentanyl
WA2023-09-14

Inquest into the Death of Shane Reynold NARRIER

40y · Male·coronary artery atherosclerosis

Shane Narrier, a 40-year-old Aboriginal man, died from coronary artery atherosclerosis on 5 June 2020 at Acacia Prison. On 27 May 2020, he reported chest pains via the Custody Messaging System (CMS) to a prison nurse. Th…

cardiologyemergency medicinediagnosticcommunicationescitalopram
VIC2023-09-14

Finding into death of Darren Ricky Culleton

31y · Male·Hypoxic ischaemic encephalopathy following out of hospital cardiac arrest in a m…

31-year-old Darren Culleton died from hypoxic brain injury after choking on the hood of his coveralls while in police custody. He had presented to St Vincent's Hospital with acute intoxication and self-harm behavior (att…

emergency medicinepsychiatrycommunicationsystemmethamphetamine

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