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WAcommunity2023-02-28

Inquest into the Death of Paul James BRADY

35y · Male·multiple injuries

Paul James Brady, aged 35, died from multiple injuries sustained after jumping from a third-floor apartment balcony on 15 May 2020. Two police officers arrived at the scene within minutes of receiving a call about a man …

emergency medicineforensic medicineproceduraldelaytemazepam
VIChospital2023-02-28

Finding into death of Mrs K

81y · Female·Cardiac tamponade secondary to dissection of ascending aorta

An 81-year-old woman with hypertension and hypercholesterolaemia presented to the ED with sudden-onset central chest pain radiating to the jaw. Despite appropriate initial assessment and ruling out acute coronary syndrom…

emergency medicinecardiologydiagnosticdelayaspirin
NT2023-02-24

Inquest into the death of Bernard Hector

31y · Male·self-inflicted hanging

Bernard Hector, a 31-year-old Aboriginal man, died by self-inflicted hanging in Darwin Correctional Centre on 30 August 2021. He was remanded on serious charges and initially placed 'at risk' following his court appearan…

psychiatrycorrectional healthcommunicationsystem
VIChospital2023-02-24

Finding into death of Justin Patrick Crome

39y · Male·Injuries sustained in a fall from the Camberwell train station bridge

Justin Crome, a 39-year-old man with delusional disorder and schizophrenia, died by suicide after jumping from a railway bridge on 13 February 2020. He had a history of mental illness since 2016, multiple psychiatric adm…

psychiatryemergency medicinecommunicationdelaypaliperidone
WAhospital2023-02-22

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)

7-year-old Aishwarya Aswath Chavittupara died from multiorgan failure due to fulminant sepsis (Streptococcus pyogenes) after approximately 90 minutes in Perth Children's Hospital emergency department. She presented with …

emergency medicinepaediatricsdiagnosticcommunication
VIChospital2023-02-22

Finding into death of Christine Ann Stephen

67y · Female·Intra-abdominal sepsis complicating an anastomotic leak following elective surge…

A 67-year-old woman died from intra-abdominal sepsis following an anastomotic leak from elective colorectal surgery to repair a vesico-colic fistula. The initial surgery on 1 November 2017 was appropriately performed, an…

colorectal surgeryintensive carecommunicationdelaynoradrenaline
VICaged care2023-02-20

Finding into death of Terence Michael Brooks

76y · Male·Streptococcus pneumoniae sepsis in the setting of acute bronchopneumonia and ren…

Terence Michael Brooks, a 76-year-old man with dementia, vascular disease, and depression, died of streptococcal pneumoniae sepsis with acute bronchopneumonia and renal failure from obstructive uropathy at an aged care f…

geriatric medicinegeneral practicecommunicationdelayvenlafaxine
QLDhospital2023-02-13

Hunter- Non-inquest findings

8y · Male·ischaemic bowel due to strangulated small bowel obstruction secondary to congeni…

An eight-year-old boy with autism spectrum disorder (level 1) died from ischaemic bowel due to strangulated small bowel obstruction from a rare congenital band adhesion. He presented to a regional hospital with abdominal…

surgerypaediatricsdiagnosticcommunicationondansetron
ACT2023-02-10

Inquest into the death of Joshua

18y · Male·asphyxia by hanging; intentional self-harm

Joshua, 18, died by suicide at an ANU residential hall in August 2018, several weeks after a serious self-harm incident requiring hospitalisation. Key clinical lessons emerge: (1) Inadequate coordination between ACT Ment…

psychiatryemergency medicinecommunicationsystemsertraline
NSWhospital2023-02-10

Inquest into the death of Anzac Sullivan

38y · Male·Combined effects of coronary atherosclerosis and cardiomegaly, with methylamphet…

Anzac Sullivan, a 38-year-old Aboriginal man, died of a cardiac arrhythmia secondary to severe underlying cardiac disease (coronary atherosclerosis, cardiomegaly, and possible QT prolongation) while fleeing from police a…

cardiologyforensic medicinedelaymethamphetamine
VIChome2023-02-01

Finding into death of Michael Andrew Power

31y · Male·Stab wound to the neck

Michael Power, aged 31, was fatally stabbed in the neck by his de facto partner Stacey Edwards on 22 November 2016 following an escalating pattern of bidirectional family violence. While Edwards perpetrated the fatal ass…

systemcommunicationmethamphetamine
VIC2023-02-01

Finding into death of Hassan Jeng

23y · Male·Stab wounds to the chest and back

Hassan Jeng, a 23-year-old remand prisoner with a history of mental illness and substance use, was fatally stabbed multiple times in his cell at Port Phillip Prison on 1 January 2018. CCTV footage clearly documented the …

forensic medicinecorrectional healthsystemdelayfluoxetine
SAcommunity2023-01-31

Coroner's Finding: Bromage, Ronald

72y · Male·acute cerebral infarction complicating acute myocardial infarction

Ronald Bromage, aged 72, died from acute cerebral infarction complicating acute myocardial infarction. He presented with chest pain on 22 and 25 February 2016 to his GP, Dr P., who diagnosed costochondritis without perfo…

general practicecardiologydiagnosticdelayparacetamol/codeine
ACThospital2023-01-30

Inquest into the Death of Maarouf El-Cheikh

57y · Male·streptococcus pneumonia septicaemia due to splenectomy

Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…

emergency medicineintensive carediagnosticmedicationceftriaxone
VIChome2023-01-30

Finding into death of Veronica Nelson

37y · Female·complications of withdrawal from chronic opiate use and Wilkie Syndrome in the s…

Veronica Nelson, a 37-year-old Aboriginal woman with opioid dependence, was arrested on minor theft charges, remanded in custody following a bail hearing, and held at Dame Phyllis Frost Centre (DPFC) women's prison. She …

general practiceaddiction medicinediagnosticsystembuprenorphine/naloxone
QLD2023-01-25

Civic, Mirko

70y · Male·Coronary atherosclerosis

Mirko Civic, a 70-year-old prisoner with a significant cardiac history including prior myocardial infarction, hypertension, and ischaemic heart disease, died of coronary atherosclerosis in September 2018. Critical clinic…

cardiologygeneral practicediagnosticmedicationaspirin
VIChome2023-01-23

Finding into death of Cody Morrella Watson

19y · Female·Hanging

Cody Watson, 19, died by hanging following childhood sexual abuse, family violence, and inadequate trauma-informed care. She disclosed abuse at 15, subsequently developing borderline personality disorder, anxiety, depres…

general practicepsychiatrysystemdelayvenlafaxine
VIChome2023-01-19

Finding into death of Danny Lee O'Brien

37y · Male·Stab wound to the chest

Danny Lee O'Brien, aged 37, was fatally stabbed in the chest by his intimate partner Kerry Jones on 9 December 2016 during an argument at his boarding house. He had previously assaulted Ms Jones, leading to a Family Viol…

systemcommunicationmethamphetamine
VIChospital2023-01-18

Finding into death of S J

24y · Male·Injuries sustained in fall from height

SJ, a 24-year-old man with recently diagnosed Stage 4B non-Hodgkin lymphoma and pre-existing depression managed by Orygen Youth Health, died by suicide on 22 September 2016 by jumping from the seventh-floor rooftop garde…

psychiatryhaematologycommunicationdelaymetoclopramide
VIChome2023-01-17

Finding into death of Steven John Bamblett

29y · Male·Hanging

Steven John Bamblett, a 29-year-old Aboriginal man, died by hanging on 14 January 2020 following service of a Family Violence Intervention Order application. He had a documented history of untreated mental illness with f…

psychiatryforensic medicinecommunicationsystemcannabis

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