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VICcommunity2021-11-29

Finding into death of Felicity Ruth Loveday

83y · Female·unascertained

Felicity Ruth Loveday, aged 83, disappeared and is presumed deceased after setting sail from Port Phillip Bay on 11 December 2019 with her son. Ms Loveday had significant medical and cognitive vulnerabilities including s…

general practicegeriatric medicinesystemdelay
NSWhospital2021-09-28

Inquest into the death of Gwenith ELKINGTON

60y · Female·acute cerebral bleed resulting from blunt trauma and late haemorrhagic progressi…

Gwenith Elkington, aged 60, died from acute cerebral bleed resulting from haemorrhagic progression of a traumatic brain injury sustained in a bathroom fall on 21 September 2015. The injury caused a contre coup contusion …

emergency medicineneurosurgerydelaycommunicationibuprofen
NSWaged care2021-09-22

Inquest into the death of Vakabauta LEONE

47y · Female·complications of rapidly progressing motor neurone disease

A 47-year-old woman with motor neurone disease died from respiratory complications while in immigration detention, residing in aged care. She collapsed at 1:00am with respiratory distress. Nursing staff did not attempt C…

palliative careemergency medicinecommunicationdelay
QLDcommunity2021-09-10

Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings

49y · Female and male·Gunshot wound to head inflicted by spouse

Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…

general practicepsychiatrydiagnosticcommunicationcannabis
TAScommunity2021-08-26

Coroner's Finding: Quirk, Stewart James

Male·sternum, rib and thoracic spine fractures, haemothorax and mediastinal haemorrha…

Stewart James Quirk died from thoracic trauma sustained in a motor vehicle collision on 13 October 2020. He was driving a van while speaking on his mobile phone and collided with a taxi at appropriate speed on clear weat…

neurologyforensic medicinedelay
VIChome2021-08-20

Finding into death of Samantha Louise Leech

28y · Female·Complications of a seizure in the setting of prescription drug abuse (pregabalin…

Samantha Leech, 28, died from complications of a seizure in the setting of prescription drug abuse, particularly pregabalin. She obtained approximately 4000 pregabalin tablets over three months by visiting multiple GPs, …

general practicecardiologydiagnosticsystempregabalin
QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

Teresa Bradford, aged 40, was killed by her husband David Bradford in a premeditated domestic homicide at their Pimpama home on 31 January 2017, followed by his suicide. She died from head injuries inflicted with an axe.…

general practicepsychiatrycommunicationsystemwarfarin
NSWcommunity2021-05-21

Inquest into the death of Pono Wairua Aperahama

17y · Male·Cardiac arrhythmia during restraint, with previous traumatic brain injury as a s…

Pono Aperahama, a 17-year-old with severe traumatic brain injury and moderate intellectual disability, died from cardiac arrhythmia during restraint at a swimming pool. His escalating behaviour in 2017—triggered by schoo…

neurologypsychiatrysystemcommunication
QLD2021-05-04

Hambly, Scott

38y · Male·Aspiration pneumonia

Scott Hambly, a 38-year-old life prisoner with dilated cardiomyopathy, epilepsy, and schizophrenia, died from aspiration pneumonia at Wolston Correctional Centre in December 2018. He was identified as needing cardiology …

cardiologypsychiatrycommunicationsystembisoprolol
WAhome2021-04-16

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

3y · Female·tramadol toxicity

A 3-year-old girl in state care died from tramadol toxicity after accessing prescribed opioid medication left unsecured in her carer's bedroom. The child was removed from her mother's care due to neglect and substance ab…

paediatricsforensic medicinesystemdelaytramadol
VIChome2021-03-31

Finding into death of Jordan

22y · Male·Hypoxic/ischaemic encephalopathy secondary to restraint in the context of combin…

A 22-year-old male died from hypoxic-ischaemic encephalopathy following restraint during acute intoxication with novel psychoactive substances (NPS). He unknowingly ingested 25C-NBOMe and 4-fluoroamphetamine (sold as MDM…

toxicologyintensive caresystemdelay25c-nbome
SA2021-01-15

Coroner's Finding: BALLARD Kenneth Frederick

75y · Male·cerebral metastatic malignancy (lung cancer with brain metastases)

Kenneth Ballard, aged 75, died in prison custody from cerebral metastatic lung cancer. He had been diagnosed with chronic lymphocytic lymphoma in 2012 and managed at Mount Gambier Prison. In late 2014, Mr Ballard refused…

general practicehaematologydiagnosticdelay
TAShome2020-07-17

Coroner's Finding: Thompson, Paul Christopher

57y · Male·acute subdural haematoma, cause undetermined (could result from trauma, fall, se…

Paul Thompson, aged 57, died from acute subdural haematoma (brain bleeding). He was found unresponsive after an evening of heavy alcohol consumption with his housemate Lawrence Kean, who punched him during an altercation…

forensic medicineneurologydelayalcohol
QLDcommunity2020-06-26

Nyholt, Nicole Sonia and Clark, Margaret Louisa

Female·Burns due to gas explosion due to motor vehicle collision with building

A 60-year-old man with a long-standing history of seizures experienced an epileptic seizure while driving and lost control of his vehicle. It collided with an LPG gas cylinder outside a café, triggering an explosion that…

emergency medicineneurologycommunicationsystem
TAShospital2020-04-07

Coroner's Finding: Pettersson, Jan Axel

71y · Male·disseminated fungal (Cryptococcus) infection of the lungs, brain and meninges

A 71-year-old man presented with fever, confusion, and gait disturbance in October 2017. A lung mass was identified on chest X-ray and presumed malignant, but inflammatory markers were unremarkable. Despite clinical dete…

general medicinerespiratory medicinediagnosticdelay
NSW2020-02-28

Inquest into the death of Eric WHITTAKER

35y · Male·subarachnoid haemorrhage with antecedent ruptured cerebral artery aneurysm

Eric Whittaker, a 35-year-old Aboriginal man, died from a subarachnoid haemorrhage caused by a ruptured cerebral artery aneurysm while in remand custody at Parklea Correctional Centre. On 2 July 2017, he made 20 emergenc…

correctional healthneurologydiagnosticcommunicationamphetamine
VIChospital2020-02-28

Finding into death of Keith Walter Sharp

63y · Male·Cerebral infarction complicating vertebral artery dissection following motor veh…

Keith Walter Sharp, 63, sustained a motor vehicle collision causing vertebral artery dissection and subsequent cerebral infarction. At Albury Base Hospital, initial CT imaging at 10:44am identified significant cervical s…

emergency medicineradiologydelaydiagnosticaspirin
VIChome2020-02-25

Finding into death of Laurie Henry Cartledge

44y · Male·Heroin toxicity in the setting of ischaemic heart disease

Laurie Cartledge, a 44-year-old man with intellectual disability and acquired brain injury, died from heroin toxicity complicated by severe coronary artery atherosclerosis just one day after release from prison. He had b…

forensic medicineaddiction medicinesystemcommunicationheroin
NSWhospital2020-01-31

Inquest into the death of OS

5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …

A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…

plastic and reconstructive surgeryanaesthesiamedicationproceduralmorphine
VIChome2020-01-14

Finding into death of H B

8y · Female·Aspiration pneumonia in a child with an epileptic encephalopathy and extreme cac…

HB, age 8 years 10 months, died from aspiration pneumonia with extreme cachexia (BMI 7). She had severe cerebral palsy, epilepsy (Lennox-Gastaut syndrome), and was entirely dependent on PEG tube feeding. Between January …

paediatricsneurologydiagnosticdelaylevetiracetam

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