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WAcommunity2022-02-25

Inquest into the Suspected Death of Crispin MITCHELL

54y · Male·Unknown; likely drowning in Cambridge Gulf waters, but exact cause could not be …

Crispin Mitchell, aged 54, disappeared on 20 February 1987 while travelling by small aluminium dinghy across Cambridge Gulf in rough weather with two companions. All three men were intoxicated; the dinghy lacked safety e…

delay
VIChospital2022-02-25

Finding into death of Joseph Cardona

49y · Male·haemopericardium secondary to ruptured aortic dissection

Joseph Cardona, 49, died from ruptured aortic dissection with haemopericardium. He presented to the ED twice within 24 hours with severe central chest pain radiating to jaw, neck, and back, associated with hypertension. …

emergency medicinecardiologydiagnosticcommunicationoxycodone
NSWhospital2022-02-25

Inquest into the death of Carley METCALFE

41y · Female·unable to determine

Carley Metcalfe, aged 41, was found deceased in the Brunswick River in November 2017, three weeks after disappearing. She had presented to Lismore Base Hospital on 1-2 November 2017 with acute psychosis related to schizo…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
VICcommunity2022-02-24

Finding into death of Peter Trimbos

52y · Male·Head injuries

Peter Trimbos, a 52-year-old lawyer, died by suicide following overwhelming psychological distress from multiple stressors: the deaths of his parents and father-in-law from COVID-19, and involvement in a highly publicise…

general practicepsychiatrysystemdelay
VIChospital2022-02-22

Finding into death of Matthew Lee Dongelmans

30y · Male·Complications of methylamphetamine toxicity

Matthew Dongelmans, aged 30, died from complications of methylamphetamine toxicity after being arrested for breaching a family violence intervention order. He consumed methylamphetamine prior to arrest, likely in panic w…

emergency medicineintensive caredelaysystemmethamphetamine
TAShome2022-02-18

Coroner's Finding: FL de-identified

17y · Unknown·hypoxic brain damage from out of hospital cardiac arrest

FL was a 17-year-old with complex medical needs including short bowel syndrome and dependence on total parenteral nutrition (TPN) via central vascular access device. In June 2020, he became severely unwell with deteriora…

paediatric surgerygastroenterologydiagnosticdelay
SA2022-02-09

Coroner's Finding: Curran, Michael Anthony

62y · Male·metastatic hepatocellular carcinoma

Michael Anthony Curran, a 62-year-old prisoner, died from metastatic hepatocellular carcinoma in 2015. He had been diagnosed with hepatitis C in 2005, which is a significant risk factor for liver cancer. A liver biopsy i…

hepatologygastroenterologydiagnosticsystemribavirin
TAShospital2022-02-08

Coroner's Finding: KN - deidentified

0y · Male·global hypoxic ischaemic encephalopathy

A term breech baby was born at Launceston General Hospital following a traumatic vaginal delivery with instrumental assistance after failed initial extraction attempts. The infant suffered severe hypoxic-ischaemic enceph…

obstetricsmidwiferydiagnosticdelay
VIC2022-02-03

Finding into death of Wayne Myhill

54y · Male·Neck injuries sustained in a fall - fracture of the fifth cervical vertebra (car…

Wayne Myhill, aged 54, died from a cervical spine fracture (C5 level) sustained in a fall at his group home in Ararat, Victoria. He had cerebral palsy, intellectual disability, Lennox-Gastaut syndrome with frequent seizu…

neurologygeneral practicesystemdelaylamotrigine
VIC2022-02-01

Finding into death of Travis Thomas Young

42y · Male·hanging

A 42-year-old prisoner with generalised anxiety disorder and chronic tinnitus causing significant distress died by suicide while incarcerated. In the months preceding his death, he presented repeatedly to health staff re…

psychiatrygeneral practicesystemdelaymethadone
NSWmental health2022-02-01

Inquest into the death of Camilla MARGOLIS

34y · Female·multiple blunt force injuries

Camilla Margolis, 34, died by suicide at Echo Point Lookout in the Blue Mountains hours after discharge from mental health inpatient care. She had complex borderline personality disorder with chronic suicidality across 2…

psychiatryemergency medicinecommunicationsystemmirtazapine
NSWhospital2022-02-01

Inquest into the death of Ivan CHRISTOV

70y · Male·complications of chronic obstructive pulmonary disease and ischaemic heart disea…

A 70-year-old man with end-stage COPD, ischaemic heart disease, and obstructive sleep apnoea collapsed in his prison cell and was transferred to hospital in respiratory distress. Despite having documented 'not for resusc…

emergency medicinerespiratory medicinecommunicationdelay
WAhospital2022-01-25

Inquest into the Death of Carole LIVESEY

54y · Female·unascertained

Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…

psychiatrygeneral medicinecommunicationproceduralfluoxetine
NThospital2022-01-25

Inquest into the death of Josef Lear

80y · Male·metastatic oesophageal cancer

Josef Lear, an 80-year-old prisoner, died of metastatic oesophageal cancer at the Royal Darwin Hospital Hospice on 7 March 2021. He presented with progressive dysphagia, cough, and weight loss in mid-2020, which was appr…

oncologygastroenterologycommunicationsystemibuprofen
NSW2022-01-25

Inquest into the death of Nick NEWMAN

33y · Male·Multiple gunshot wounds

Nick Newman, 33, died from multiple gunshot wounds during execution of an arrest warrant for serious child sexual assault offences. Police conducted inadequate risk assessment despite accessible intelligence indicating h…

diagnosticcommunication
TAShospital2022-01-21

Coroner's Finding: de Wit, Pauline Catherine Marie

53y · Female·acutely decompensated congestive cardiac failure due to blunt traumatic injuries…

A 53-year-old woman with severe intellectual disability and scoliosis died from acute decompensated congestive cardiac failure following blunt traumatic injuries sustained in a five-vehicle motor vehicle crash. She was a…

emergency medicineintensive caresystemdelay
VICcommunity2022-01-20

Finding into death of YLM

78y · Male·Ruptured abdominal aortic aneurysm

A 78-year-old man died from rupture of a previously undiagnosed 7.1cm abdominal aortic aneurysm. A CT scan ordered for suspected renal colic incidentally discovered the aneurysm and recommended vascular review. The GP ap…

general practiceradiologycommunicationsystem
WAhospital2022-01-17

Inquest into the Death of Peter Johnnie YOUNG

Male·Complications of alcohol and hepatitis C-related liver disease

Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…

hepatologygastroenterologysystemdelayquetiapine
WAhome2022-01-17

Inquest into the Death of Shaun Andrew WILLIS

54y · Male·Ligature compression of the neck (hanging)

Shaun Willis, aged 54, died by hanging at his home on 8 March 2019 following a turbulent separation and family violence history. He was arrested on 7 March for assaulted his ex-wife and served with a Family Violence Rest…

communicationsystemalcohol
VICcommunity2022-01-17

Finding into death of Parth Dayalal Patel

23y · Male·Asphyxia from helium and plastic bag over head

Parth Patel, a 23-year-old international student from India, died by asphyxia from helium inhalation via plastic bag. He had experienced undiagnosed depression characterized by social withdrawal, disengagement from studi…

psychiatrygeneral practicedelayhelium

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