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VICaged care2020-01-13

Finding into death of Annie Chettle

74y · Female·Subdural haemorrhage following a fall in a woman with multiple medical comorbidi…

Mrs Chettle, a 74-year-old aged care resident with multiple comorbidities including dementia, schizoaffective disorder, and a nine-fall history in twelve months, fell from a shower chair while a personal care assistant b…

geriatric medicineemergency medicinediagnosticcommunication
NSWhospital2019-12-17

Inquest into the death of Alan BUGDEN and Amaru BESTRIN

Unknown·Alan Bugden: pulmonary thromboembolism after stroke. Amaru Bestrin: combined dru…

Two deaths occurred in hospital toilets due to undetected collapse in publicly accessible facilities. Alan Bugden, 66, suffered a stroke in an ambulatory care centre toilet at Royal North Shore Hospital and remained unde…

emergency medicineneurologysystemcommunicationheroin
NThospital2019-11-22

Inquest into the death of Lebron Douglas Martin

4y · Male·respiratory failure secondary to pneumonia on a background of Niemann Pick Type …

Lebron Martin was a 4-year-old Aboriginal child with Niemann-Pick Type C disease, a progressive neurodegenerative disorder. He died from respiratory failure secondary to pneumonia in December 2017. Four months prior to h…

paediatricsneurologysystemcommunicationamoxicillin
QLDhome2019-11-06

Follent, Mitchell James - Non-inquest findings

22y · Male·Multiple injuries from fall from height

Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired b…

psychiatryneurologydiagnosticcommunicationolanzapine
QLD2019-08-30

Pike, Kerri Anne; Dawson, Peter Michael and Turner, Tobias John

Unknown·multiple physical injuries sustained in a mid-air collision during skydiving

Three skydivers died in a mid-air collision near Mission Beach, Queensland on 13 October 2017. Tandem instructor Peter Dawson and customer Kerri Pike (in drogue-fall) collided with solo sport jumper Tobias Turner whose m…

aviation medicineneurologysystemdelaynordiazepam
ACThospital2019-08-22

Inquest into death of Sebastian Nicholas Pelle

20y · Male·sudden unexplained death in epilepsy (SUDEP); right frontal lobe epidermal cyst …

A 20-year-old man with a history of seizures and a previously resected frontal lobe cyst presented to hospital with severe headaches. Despite his significant medical history of epilepsy and prior neurosurgery, he was dis…

neurologyemergency medicinediagnosticdelayparacetamol/codeine
TAShospital2019-07-25

Coroner's Finding: Horcicka, Josef Vratislav

89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…

An 89-year-old man with Parkinson's disease fell at home on 16 August 2016, sustaining a cervical spine fracture. Initial CT imaging missed the C5 inferior articular process fracture, reporting only a paraspinal haematom…

orthopaedic surgeryemergency medicinediagnosticproceduralmorphine
WAhome2019-06-12

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

13y · Male·Epileptic seizure with aspiration

Child L, a 13-year-old boy with autism, cognitive impairment and poorly controlled generalised epilepsy, died from sudden unexpected death in epilepsy (SUDEP) with aspiration. His seizures remained refractory despite app…

neurologypaediatricsmedicationcommunicationlevetiracetam
VICaged care2019-05-30

Finding into death of S B

87y · Male·Complications of head injuries in setting of dementia

An 87-year-old man with vascular dementia died from complications of head injuries sustained in assaults by a fellow nursing home resident. The deceased had a documented tendency to wander and enter other residents' room…

geriatric medicineforensic medicinesystemcommunicationclopidogrel
WAhospital2019-05-14

Inquest into the Death of SM (Subject to Suppression Order)

7y · Male·Complications following cardiorespiratory arrest in association with a seizure i…

SM was a 7-year-old Aboriginal boy with severe cerebral palsy, intellectual disability, chronic seizures, and recurrent respiratory infections who died from cardiorespiratory arrest following a seizure while hospitalized…

paediatricsneurologydelay
WAcommunity2019-02-06

Inquest into the Death of Torran Jake THOMAS

15y · Male·Multiple organ failure associated with hyperthermia (heat stroke)

A 15-year-old rugby league player died from heat stroke during training on an extremely hot Perth summer evening (44.4°C). The coaching staff appropriately applied NRL heat guidelines in deciding to proceed with modified…

emergency medicineintensive carediagnosticdelay
WA2018-12-27

Inquest into the Death of Mohammad Nasim NAJAFI

24y · Male·seizure (epileptic)

Mohammad Nasim Najafi, a 24-year-old Afghan detainee with well-controlled epilepsy, died from a seizure after missing multiple doses of carbamazepine in the days preceding his death. He was held in immigration detention …

neurologygeneral practicesystemdelaycarbamazepine
VICcommunity2018-12-18

Finding into death of LF M

52y · Male·Multiple injuries sustained in a motor vehicle incident (driver) in a man with a…

A 52-year-old man with epilepsy died in a motor vehicle collision when his car struck a parked truck at high speed with no evidence of braking. Witness accounts and collision reconstruction suggested he experienced a sei…

neurologycardiologycommunicationsystemtopiramate
SAhospital2018-12-06

Coroner's Finding: RUSSELL Michael John and GRAHAM Leslie Robert

Unknown·Michael Russell: intracranial haemorrhage complicating surgery for right cerebra…

Two patients died following stroke interventions on 18 April 2017 at the Royal Adelaide Hospital. Michael Russell (60) died from intracranial haemorrhage following vessel perforation during thrombectomy for acute coronar…

radiologyneurologycommunicationsystemticagrelor
TAScommunity2018-12-05

Coroner's Finding: Webb, Shanelle Jean

22y · Female·Sudden Unexpected Death in Epilepsy (SUDEP)

22-year-old woman with epilepsy, cognitive disability and schizophrenia died of Sudden Unexpected Death in Epilepsy (SUDEP) during respite care. She experienced a nocturnal seizure while sleeping at a disability support …

neurologydisability medicinesystemdelayolanzapine
SAhospital2018-10-10

Coroner's Finding: ATKINS Stephen Robert

53y · Male·fentanyl and oxycodone toxicity

Stephen Robert Atkins, 53, died from fentanyl and oxycodone toxicity after admission to Flinders Medical Centre for investigation of Horner's syndrome and radiculopathy. Over three days, escalating opioid doses were pres…

neurologyemergency medicinediagnosticmedicationfentanyl
WAhome2018-09-21

Inquest into the Death of Pamella Leslie REES

63y · Female·disseminated metastatic carcinoma of unknown primary in a woman with multiple sc…

Pamella Rees, a 63-year-old woman with longstanding multiple sclerosis, died on 30 June 2014 from disseminated metastatic carcinoma of unknown primary. Her cancer went undiagnosed despite regular GP contact. In her final…

general practiceneurologydiagnosticcommunicationcodeine
WAhospital2018-06-25

Inquest into the Death of LCTM

0y · Male·complications of head injury

A premature newborn died from severe head injuries inflicted deliberately by his teenage father in hospital on 15 February 2014. The father had a well-documented history of violence, substance abuse, criminality and had …

neonatologypaediatricscommunicationsystem
VIChome2018-06-06

Finding into death of Rohan Grindrod

41y · Male·Sudden unexpected death in epilepsy (SUDEP)

Rohan Grindrod, a 41-year-old man with acquired brain injury and epilepsy following a 2007 motor vehicle accident, died of Sudden Unexpected Death in Epilepsy (SUDEP) at his home on 16-17 November 2011. He had a Personal…

neurologyoccupational therapysystemcommunicationcarbamazepine
QLDaged care2018-06-05

Milward, Paul Joseph

53y · Male·Choking on food bolus in pharynx, with Huntington's disease and coronary atheros…

Paul Joseph Milward, aged 53 with Huntington's disease causing cognitive impairment and swallowing difficulties, died from choking on a bread sandwich while unsupervised in his aged care room. His care plan specified min…

geriatric medicinespeech pathologycommunicationsystemsodium valproate
13458

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