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NSW2020-10-23

Inquest into the death of Ye Chiu

67y · Male·Head injuries sustained from a fall from the upstairs landing in Goldsmith G Blo…

Ye Chiu, a 67-year-old Chinese-speaking prisoner on remand, died by suicide in prison on 6 February 2017 after falling head-first from a landing. He had a complex psychiatric history including anxiety, depression, hypona…

psychiatryemergency medicinesystemcommunicationparoxetine
VIChospital2020-10-21

Finding into death of Baby ABA

0y · Female·Head injury

Baby ABA, born in Lebanon and arrived in Australia at 2 months old, died from head injury at 6.5 months of age on 10 June 2008. She had fallen from a couch on 7 June 2008 with no apparent serious injury. The following mo…

paediatricsintensive caredelay
VIChospital2020-10-13

Finding into death of BABY C

0y · Male·Myocarditis

Baby C, a 5-month-old infant, died from myocarditis (viral heart inflammation) after presenting to Sunshine Hospital Emergency Department with fever, breathing difficulty, and cyanosis. He waited 1 hour 52 minutes before…

emergency medicinepaediatricsdiagnosticdelayparacetamol
TASmental health2020-10-09

Coroner's Finding: Le Roy, Carole Ann

40y · Female·hypoxic encephalopathy due to asphyxia from hanging

A 40-year-old woman with extensive mental health history including OCD, complex trauma, severe depression, and recurrent suicidal ideation was admitted to an open psychiatric unit after expressing suicidal intent. Despit…

psychiatryintensive carediagnosticsystem
NSWout of home care2020-10-02

Inquest into the disappearance of Katrina BOHNENKAMP

15y · Female·Unknown - insufficient evidence for finding

This coronial finding concerns the disappearance and suspected death of Katrina Bohnenkamp, a 15-year-old girl in state care who was last seen on 26 October 2012. While not a traditional medical case, the finding highlig…

systemcommunicationheroin
VIChome2020-09-28

Finding into death of JC

17y · Male·Hanging

A 17-year-old male with a history of mental health concerns, prior suicide pact attempt, and escalating aggressive behaviour died by hanging shortly after being excluded from his home via a Family Violence Intervention O…

psychiatryemergency medicinesystemcommunicationdiazepam
ACTcommunity2020-09-25

Inquest into the death of ANTHONY ROMANAS CARISTO

54y · Male·Cardiac arrest in a person with cardiac hypertrophy and generalised atherosclero…

Anthony Caristo died from cardiac arrest on 31 October 2017 following police deployment of a taser during a mental health crisis. He had consumed a lethal dose of methamphetamine, was actively self-harming with knives, a…

emergency medicineparamedicinedelaysystemmethamphetamine
SAmental health2020-09-22

Coroner's Finding: NOONAN Ricky Dale

54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking

A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to…

psychiatryemergency medicinecommunicationsystemhaloperidol
VICmental health2020-09-18

Finding into death of Harley Robert Larking

23y · Male·Effects of fire

Harley Larking, a 23-year-old Aboriginal man with treatment-resistant schizoaffective disorder, died from effects of fire on 13 May 2016 while absconding from a psychiatric unit. He was on clozapine for only two weeks wh…

psychiatryAboriginal healthsystemdelayclozapine
VIChome2020-09-11

Finding into death of Mr A

44y · Male·compression of the neck consequent upon hanging

A 44-year-old man with a 42-year history of intimate partner violence died by hanging. He had recently separated from his wife and was enrolled in a 18-week men's behaviour change program, having completed 17 of 18 sessi…

general practicepsychiatrysystemdelayalcohol
QLDcommunity2020-09-07

C - Non-inquest findings

6y · Male·Sepsis due to melioidosis

A six-year-old previously healthy boy died from sepsis due to melioidosis after multiple presentations to a remote hospital over five days (5–10 January 2017) with fever, vomiting, diarrhoea, and headache. Initial diagno…

paediatricsinfectious diseasesdiagnosticcommunicationparacetamol
VICcommunity2020-09-07

Finding into death of Ms WX

40y · Female·Injuries sustained when struck by a train (in circumstances where the deceased i…

A 40-year-old South Asian woman died by suicide when struck by a train, four weeks after arriving in Australia. She was deeply distressed by financial circumstances—construction delays on her new home and storage fees fo…

psychiatrygeneral practicesystemdelay
WAhospital2020-09-04

Inquest into the Death of Malakai Matiu Ward PARAONE

0y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…

Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. …

emergency medicineintensive carediagnosticcommunicationparacetamol
NSWcommunity2020-09-04

Inquest into the death of Thomas HUNT

27y · Male·unascertained; likely death from entering water

Thomas Hunt, a 27-year-old man, died after entering the water near Bondi Beach on 23 March 2017, likely after experiencing an acute mental health crisis characterised by paranoid delusions and auditory hallucinations. Mu…

psychiatrygeneral practicediagnosticcommunication
QLDcommunity2020-08-27

Master Carr and Jaylen

17y · Male·multiple injuries due to motor vehicle collision

Two juvenile males, aged 17 and 16, died in a high-speed motor vehicle crash on the Gore Highway near Wyaga Creek on 21 April 2018. The vehicle, a stolen Holden Commodore, was traveling at approximately 170-175 km/h when…

forensic medicineproceduralsystemmethamphetamine
TAScommunity2020-08-26

Coroner's Finding: Harmon, Trinton John

43y · Male·Multiple injuries sustained in motor vehicle crash

Trinton Harmon, a 43-year-old intoxicated male with high alcohol and methamphetamine levels, was struck by a vehicle driven by Simone Bridges while walking on the South Arm Highway at night. He sustained fatal traumatic …

communicationdelayalcohol
QLDhospital2020-08-26

Baby C - non-inquest findings

0y · Male·meconium aspiration syndrome complicated by persistent pulmonary hypertension

Baby C was born at 41 weeks and 2 days covered in thick meconium with respiratory distress. Key clinical failures included: (1) failure to respond to mother's request for induction at term+6 days; (2) failure to investig…

neonatologyobstetricsdiagnosticproceduralmorphine
VIChome2020-08-24

Finding into death of Brittany Harvie

22y · Female·Complications of blunt force trauma to head, neck and chest

Brittany Harvie, aged 22, was killed by her de facto partner Mataio Aleluia in June 2015 following a 15-minute violent assault involving repeated punching to the head, neck and chest. She died from complications of blunt…

forensic medicinepsychiatrycommunicationsystemcannabis
WAcommunityPodcast2020-08-18

Inquest into the Death of Jessica Lesley JACKSON

18y · Female·multi-organ failure due to combined effects of environmental exposure (hyperther…

Jessica Jackson, 18, died from multi-organ failure due to combined hyperthermia and dehydration while weight-cutting for an amateur Muay Thai fight. She lost approximately 9 kg in the final week through water-loading, de…

emergency medicinesports medicinediagnosticsystem
WAhospital2020-08-13

Inquest into the Death of Susan Jessica Elsie WINDIE

22y · Female·bowel obstruction due to faecal impaction

Susan Windie, a 22-year-old with rare congenital abnormalities affecting bowel function, died from bowel obstruction due to faecal impaction complicated by abdominal compartment syndrome. She presented to Carnarvon Hospi…

gastroenterologygeneral practicecommunicationsystemfleet enema

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