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WAhospital2023-06-29

Inquest into the Death of Child R (Name Subject to Suppression Order)

11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…

Child R, an 11-year-old Aboriginal girl with congenital anorectal anomalies causing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and vomiting. She died 12 ho…

paediatricsemergency medicinediagnosticcommunicationmacrogol
VICaged care2023-06-27

Finding into death of Elizabeth Ethel Watson

89y · Female·Complications of fractured neck of femur in the setting of a fall in a woman wit…

An 89-year-old woman with dementia and high falls risk sustained a fall at an aged care facility on 24 August 2019. The enrolled nurse in charge, on her third unsupervised shift, lacked electronic medical record access a…

geriatric medicineemergency medicinediagnosticcommunicationtramadol
QLDhospital2023-06-26

Searle, William Edward

74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …

William Searle, a 74-year-old prisoner, died from aspiration of gastric contents following a Whipple procedure for recurrent ampullary adenoma. The clinical lessons involve recognition of gastroparesis risk in high-risk …

general surgeryintensive carediagnosticcommunicationadrenaline
NSWhospital2023-06-23

Inquest into the death of Baylen Pendergast

21y · Male·Complications of blunt head injury resulting from at least two separate acts of …

Baylen Pendergast, 21 months old, died from complications of blunt head injury sustained in two separate traumatic incidents (17 and 28 November 2013). The coroner found injuries were non-accidental and resulted from sig…

paediatricsemergency medicinediagnosticcommunication
VICmental health2023-06-22

Finding into death of Catherine Ann Williamson

58y · Female·plastic bag asphyxia

Catherine Williamson, a 58-year-old voluntary psychiatric inpatient, died from plastic bag asphyxia at a private mental health facility. She had schizo-affective disorder and a history of suicide attempts. Despite return…

psychiatrysystemcommunication
NSWcommunity2023-06-16

Inquest into the death of Brandon Clark

23y · Male·In keeping with drowning

Brandon Clark, a 23-year-old Aboriginal man, died by drowning in the Manning River during a police foot pursuit on 22 January 2022. He was stopped while in a vehicle following drug intelligence, gave false identity detai…

emergency medicinetoxicologysystemdelaymethamphetamine
VIC2023-06-14

Finding into death of Robert Arthur Selby Lowe

84y · Male·Urinary tract infection in a man with Parkinson's disease

An 84-year-old man with Parkinson's disease and dementia died from urinary tract infection with sepsis while incarcerated. On 3 November 2021, he developed fever and confusion; antibiotics were commenced. The following m…

general practiceinfectious diseasescommunicationdelaycefalexin
VIChome2023-06-08

Finding into death of Mayumi Spencer

29y · Female·Cocaine toxicity

Mayumi Spencer, a 29-year-old woman, died from cocaine toxicity on 17 January 2015. At approximately 4:00 AM, her husband Dr S. discovered her having a seizure and vomiting. Rather than immediately calling emergency serv…

emergency medicinetoxicologydelaysystemcocaine
NTPodcast2023-06-05

Inquest into the death of Nigel Harris

60y · Male·multiple blunt force injuries

Nigel Harris, age 60, died when struck by Trophy Truck #499 at the 35 km sand dune during the 2021 Finke Desert Race in Alice Springs, NT. The driver experienced mechanical failure (rear axle trailing arm fracture) causi…

systemdelay
VICcommunity2023-06-05

Finding into death of Brad Anthony Godressi

40y · Male·Cardiomyopathy in the setting of immersion and amphetamine use

Brad Godressi, a 40-year-old man with end-stage dilated cardiomyopathy recently discharged against medical advice from ICU, died from cardiomyopathy in the setting of immersion and amphetamine use while operating a boat …

cardiologyintensive caresystemdelayamphetamine
WAhospital2023-05-26

Inquest into the Death of Jacob George Isaac TAULELEI

28y · Male·Multiple injuries sustained when struck by a freight train

Jacob Taulelei, a 28-year-old man with long-standing depression, anxiety, and suicidal ideation, presented to St John of God Hospital on 5 February 2020 expressing intent to jump in front of a train. Despite being assess…

psychiatryemergency medicinediagnosticcommunicationduloxetine
NSW2023-05-26

Inquest into the deaths of Emma Bowden, Heather Bowden-Page, Edward Cousins, Richard Cousins, William Cousins & Gareth

Unknown·Multiple blunt force injuries and immersion secondary to seaplane crash caused b…

On 31 December 2017, a de Havilland DHC-2 Beaver seaplane crashed into Jerusalem Bay, Sydney, killing all six occupants. The coroner found the crash was caused by pilot impairment due to carbon monoxide (CO) exposure. Pr…

forensic medicinepathologyproceduralsystemcarbon monoxide
NSWcommunity2023-05-26

Inquest into the death of Benjamin Woodhouse

59y · Male·Drowning

Benjamin Woodhouse, a 59-year-old involuntary mental health patient with schizophrenia and a history of absconding, drowned in the Parramatta River while on escorted leave. Critical systemic failures included inadequate …

psychiatrycommunicationsystem
TAShome2023-05-25

Coroner's Finding: CE de-identified

69y · Male·amitriptyline and alcohol toxicity with ischaemic heart disease

A 69-year-old man with longstanding anxiety, depression, heavy alcohol use, and multiple prior intentional overdoses of amitriptyline died from combined amitriptyline and alcohol toxicity with underlying ischaemic heart …

psychiatrygeneral practicesystemcommunicationamitriptyline
VIChome2023-05-25

Finding into death of Bradley Scott Liefvoort

46y · Male·Opioid toxicity (tapentadol and oxycodone)

Bradley Liefvoort, 46, died from opioid toxicity (tapentadol and oxycodone) at home in Dandenong. Over a decade of prescription medication misuse began with ibuprofen for headaches, escalating to opioid dependence follow…

general practicepain medicinemedicationsystemtapentadol
NSWcommunity2023-05-25

Inquest into the disappearance and suspected death of Melissa CADDICK

49y · Female·Cannot be determined

Melissa Caddick, a financial advisor running a Ponzi scheme, disappeared on 12 November 2020 after ASIC executed a search warrant at her home. Her decomposed foot washed ashore 100 days later. Clinical lessons emerge: th…

psychiatryforensic medicinedelaysystem
NSW2023-05-23

Inquest into the death of JS

34y · Male·Plastic bag asphyxia

A 34-year-old man on remand died by plastic bag asphyxia at Shortland Correctional Centre on 5 May 2020, hours before his release on bail. He had disclosed anxiety and depression, made multiple self-referrals for mental …

psychiatrypsychologydiagnosticcommunication
TAS2023-05-22

Coroner's Finding: Hyde-Wyatt, Michael Phillip

61y · Male·Pulmonary aspiration of gastric contents (post seizure) due to chronic communica…

Michael Phillip Hyde-Wyatt, aged 61, died from pulmonary aspiration of gastric contents following a seizure. He had chronic communicating hydrocephalus and encephalomalacia. At 1:30am, support worker Julie Magrath observ…

general practiceneurologycommunicationdelay
TAScommunity2023-05-19

Coroner's Finding: Kirkwood, Jordan Thomas

19y · Male·hypoxic brain injury following asphyxia due to hanging

Jordan Kirkwood, a 19-year-old male, died by hanging on 30 April 2019 after being admitted to a newly established community-based mental health program (MHHITH) on 3 April 2019. He presented with depression, cannabis wit…

psychiatryemergency medicinediagnosticcommunicationfluoxetine
VIChospital2023-05-16

Finding into death of Mathew James Luttrell

43y · Male·Hanging

Mathew James Luttrell, a 43-year-old Aboriginal man with borderline personality disorder, chronic suicidal ideation and substance abuse, was admitted to Mildura Base Hospital following a suicide attempt on 11 November 20…

psychiatryemergency medicinecommunicationdelayolanzapine

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