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TAScommunity2022-07-29

Coroner's Finding: Chamberlain, Pamela Jacqueline

55y · Female·asphyxia due to choking on food (steak)

A 55-year-old woman with multiple comorbidities including morbid obesity, schizophrenia, depression, and substance use disorder died from asphyxia caused by choking on food while at a friend's home in supported accommoda…

emergency medicinepsychiatrysystemcommunicationdiazepam
VIChospital2022-07-28

Finding into death of H C

6y · Male·Global cerebral ischaemia secondary to perinatal asphyxia

HC was a neonate who died at 6 days old from global cerebral ischaemia secondary to perinatal asphyxia. He was born following an emergency caesarean section for obstructed labour and fetal distress. Key clinical lessons …

obstetricsneonatologydiagnosticcommunication
VIC2022-07-28

Finding into death of Master S

17y · Male·Unascertained in the setting of volatile substance abuse

Master S, a 17-year-old Yorta Yorta young man, died on 3 July 2017 at the Bert Williams Hostel from a cause unascertained in the setting of volatile substance abuse (chroming Rexona deodorant). He had a history of exposu…

paediatricspsychiatrycommunicationsystemrexona deodorant
WAprison2022-07-22

Inquest into the Death of Callum MITCHELL

26y · Male·ligature compression of the neck (hanging)

Callum Mitchell, aged 26, died by ligature compression of the neck (hanging) in his cell at Hakea Prison on 21 April 2019. He had a longstanding history of self-harm, severe personality disorders (borderline and antisoci…

psychiatrycorrectional healthsystemcommunicationtramadol
NSW2022-07-22

Inquest into the death of Mootijah Douglas Andrew Shillingsworth

44y · Male·Complications of a Left Temporal Lobe Abscess

Mootijah was a 44-year-old Aboriginal man who died from a brain abscess originating from an untreated chronic ear infection. He had documented hearing impairment and a history of chronic ear disease requiring ENT special…

correctional healthgeneral medicinediagnosticsystemciprofloxacin eardrops
WA2022-07-20

Inquest into the Death of Seth Gregory Victor YEEDA

19y · Male·Rheumatic heart disease (severe aortic valve regurgitation)

Seth Yeeda, 19-year-old Aboriginal male with rheumatic heart disease from childhood, died in custody from severe aortic valve regurgitation. He had required aortic valve replacement surgery since 2014. In December 2017, …

cardiologycardiothoracic surgerysystemcommunication
VIChome2022-07-19

Finding into death of Mr EZT

38y · Male·Toxicity to gamma hydroxybutyrate

A 38-year-old man with a long history of drug use and criminal offending died from gamma hydroxybutyrate (GHB) toxicity after consuming approximately 60mL of GHB whilst at home. He had been released from prison on 11 May…

toxicologyforensic medicinesystemdelaygamma hydroxybutyrate
WA2022-07-15

Inquest into the Death of Sarwan Hekmat Salman AL JHELIE

21y · Male·complications of ligature compression of the neck (hanging)

Sarwan Al Jhelie, a 21-year-old Iraqi-born man in immigration detention, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose att…

psychiatryaddiction medicinecommunicationsystemmethamphetamine
TAShome2022-07-15

Coroner's Finding: Summers, Nicholas John

41y · Male·heart failure related to exsanguination due to traumatic rupture of an arteriove…

Nicholas Summers, a 41-year-old kidney transplant recipient, died from traumatic rupture of an arteriovenous fistula with massive hemorrhage on 16 February 2016. He had returned to Tasmania under nephrologist Dr M.'s car…

nephrologyvascular surgerysystemdelay
VIC2022-07-15

Finding into death of Wiki Raymond Lowe

35y · Male·hanging

Two inmates at Karreenga Correctional Centre died by hanging within four months of each other in 2017. Mr Lowe, aged 35, died on 7 March 2017 after learning he faced a longer prison sentence than expected. Mr Thomas, age…

psychiatrycorrectional healthcommunicationsystem
VIC2022-07-15

Finding into death of Noel Thomas

42y · Male·hanging

Two prisoners at Karreenga Correctional Centre died by suicide within four months of each other. Mr Lowe, aged 35, hanged himself on 7 March 2017 after learning his prison sentence would be longer than expected. Mr Thoma…

psychiatrycorrectional healthsystemcommunication
NSWcommunity2022-07-15

Inquest into the death of C S

5y · Male·Presumed drowning

CS, aged 5 years 9 months, died by presumed drowning on 2 March 2017 in the Murray River, Moama NSW. His mother LS, who was mentally unwell and using ice, forcibly held him underwater. Multiple agencies—FACS, NSW and Vic…

paediatricspsychiatrydiagnosticsystemmethamphetamine
VIChome2022-07-14

Finding into death of Mr P

71y · Male·Exsanguination from incised wounds to the neck and wrist

A 71-year-old man with bipolar disorder, depression, alcohol addiction, and cirrhosis died by suicide via exsanguination from neck and wrist lacerations. He had stopped psychiatric medications in 2017 and was managed by …

general practicepsychiatrycommunicationsystem
QLDhome2022-07-12

Jack - Non-inquest findings

41y · Male·Stab wound to the chest

Jack, a 41-year-old man with extensive history of domestic violence perpetration across multiple relationships, died from a stab wound to the chest inflicted by his partner Sally during a domestic disturbance. Sally had …

forensic medicinecorrectional healthcommunicationsystemmethamphetamine
VIC2022-07-11

Finding into death of Mladen Jovanoski

57y · Male·Consequences of multiple injuries (from fall from elevated walkway)

Mladen Jovanoski, a 57-year-old remand prisoner, died from head injuries sustained after falling from a prison walkway on 11 April 2018. He had suspected metastatic thyroid cancer requiring urgent biopsy at a tertiary ho…

endocrinologyoncologysystemcommunication
SAmental health2022-07-08

Coroner's Finding: Cardwell, Phillip David

53y · Male·lung abscess with empyema

A 53-year-old man with schizophrenia died from lung abscess with empyema while an involuntary inpatient at a mental health facility. He had been readmitted with a respiratory infection and was treated with intravenous an…

psychiatryemergency medicinedelayclozapine
VICaged care2022-07-06

Finding into death of Catherine Ann Collier

51y · Female·Aspiration in the setting of end stage down syndrome

Catherine Ann Collier, a 51-year-old woman with Down syndrome, end-stage hydrocephalus, and severe dysphagia, died from aspiration pneumonia following a choking episode while eating. The Disability Services Commissioner …

neurologyspeech pathologysystemcommunicationsodium valproate
NSW2022-07-06

Inquest into the death of Kevin BUGMY

57y · Male·Severe coronary artery disease. It is likely that Kevin's use of inhalants in cu…

Kevin Bugmy, a 57-year-old Aboriginal man, died of severe coronary artery disease while in custody at Cessnock Correctional Centre. The coroner found the care received for his chronic inhalant use disorder was grossly in…

cardiologygeneral practicediagnosticcommunicationacetone
NSWcommunity2022-07-05

Inquest into the deaths of Darren WALLACE and T B D

Male·Darren Wallace: single gunshot wound to right side of neck. TBD: two self-inflic…

Two deaths occurred on 9 December 2015 in a tragic incident connected to a dispute within the Rebels Outlaw Motorcycle Gang. TBD, a 31-year-old former ADF member with severe post-traumatic stress disorder (PTSD), alcohol…

psychiatryemergency medicinesystemdelaysertraline
TAScommunity2022-07-04

Coroner's Finding: Leighton, Garth Mcdonald

58y · Male·chest and abdominal injuries sustained in motor vehicle collision

A 58-year-old experienced motorcycle rider died from massive chest and abdominal injuries after losing control on a rural curve and colliding with an oncoming vehicle. He was initially conscious with three doctors presen…

emergency medicinesurgerysystemdelay

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