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TAShospital2020-08-12

Coroner's Finding: Maynard, Grant Godfrey

60y · Male·multi-organ failure due to injuries sustained in motor vehicle accident, specifi…

A 60-year-old Aboriginal man with significant comorbidities (cardiomyopathy, cirrhosis, renal failure, diabetes) presented to ED following a motor vehicle accident at low speed. Despite chest imaging showing pleural effu…

emergency medicinegeneral medicinediagnosticdelaydoxycycline
TAShospital2020-08-11

Coroner's Finding: Howard, Noeline Dawn

76y · Female·pulmonary embolism due to carcinomatosis

A 76-year-old woman presented to hospital with shortness of breath and was initially diagnosed with community-acquired pneumonia and later pulmonary oedema. Both diagnoses were incorrect. She had widespread cancer (carci…

emergency medicinerespiratory medicinediagnosticdelayintravenous fluids
TAScommunity2020-08-07

Coroner's Finding: Delios, Voula 2020 TASCD 458

63y · Female·Multiple stab wounds to neck and chest

Voula Delios, a 63-year-old grocer in Hobart, was fatally stabbed by Daryl Cook on 23 July 2016, one day after his release from prison. Cook suffered from serious untreated mental illness, evidenced by extensive prison r…

psychiatrycorrectional healthdiagnosticsystemolanzapine
WAmental health2020-08-06

Inquest into the Death of Stephen Michael KELL

35y · Male·acute vomit aspiration in a man with acute large intestine obstruction (severe m…

Stephen Michael Kell, a 35-year-old man with treatment-resistant schizophrenia, died at Graylands Hospital from acute vomit aspiration in the setting of acute large bowel obstruction and clozapine-induced gastrointestina…

psychiatrygastroenterologysystemdelayclozapine
WAcommunity2020-08-04

Inquest into the Death of Shirley June FINN

34y · Female·multiple gunshot wounds to the head

Shirley Finn, a 34-year-old Perth brothel owner, was murdered on 22 June 1975, shot four times in the head in her car near Royal Perth Golf Club. The Deputy State Coroner found cause of death was multiple gunshot wounds …

forensic medicinesystemcommunication
SAhospital2020-08-04

Coroner's Finding: WILLMETT Laura Angela

0y · Female·hypoxic ischaemic encephalopathy secondary to intrapartum hypoxia

A 2-day-old neonate, Laura Angela Willmett, died from hypoxic-ischaemic encephalopathy following intrapartum hypoxia. She was born by emergency caesarean section after a planned vaginal birth after caesarean (VBAC) at a …

obstetricsmidwiferydiagnosticcommunicationparacetamol/codeine
TAShome2020-07-17

Coroner's Finding: Thompson, Paul Christopher

57y · Male·acute subdural haematoma, cause undetermined (could result from trauma, fall, se…

Paul Thompson, aged 57, died from acute subdural haematoma (brain bleeding). He was found unresponsive after an evening of heavy alcohol consumption with his housemate Lawrence Kean, who punched him during an altercation…

forensic medicineneurologydelayalcohol
TAScommunity2020-07-17

Coroner's Finding: Lyons, Matthew Clayton

47y · Male·mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam and diazepam)

Matthew Clayton Lyons, a 47-year-old man with longstanding schizophrenia, severe anxiety, and substance abuse history, died from mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam, diazepam). He had expre…

psychiatrygeneral practicecommunicationsystemquetiapine
WAhome2020-07-16

Inquest into the Death of CHILD RM

17y · Female·ligature compression of the neck (hanging)

A 17-year-old girl in state care died by suicide on 16 April 2017 after being discharged from secure care. She had experienced complex developmental trauma, family violence, sexual abuse, and severe alcohol-related liver…

paediatricspsychiatrysystemcommunicationalcohol
SAhome2020-07-16

Coroner's Finding: KEIPERT Mathew James

44y · Male·Ischaemic heart disease due to coronary atherosclerosis

Mathew James Keipert, age 44, died of ischaemic heart disease due to coronary atherosclerosis while on home detention bail. He had significant cardiovascular risk factors including hypertension, heavy smoking (40 cigaret…

cardiologygeneral practicediagnosticdelaybuprenorphine
VIChospital2020-07-16

Finding into death of Lydia Maxfield

85y · Female·Multisystem failure complicating ischaemic heart disease and ischaemic bowel in …

Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnorm…

orthopaedic surgeryanaesthesiacommunicationsystemondansetron
SAhospital2020-07-14

Coroner's Finding: DUSZYNSKI Steve Stan Peter

66y · Male·Bronchopneumonia and influenza A complicating cardiac and renal failure associat…

A 66-year-old man with cryoglobulinaemic vasculitis secondary to non-Hodgkin's lymphoma died from bronchopneumonia and influenza A complicating cardiac and renal failure. He developed delirium, agitation and paranoia dur…

nephrologyhaematologydelayolanzapine
VIChospital2020-07-14

Finding into death of Gerard Guy Vaz

61y · Male·Undetermined

Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuc…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
VICcommunity2020-07-13

Finding into death of Cameron Andrew MacLellan

44y · Male·Multiple injuries sustained in a motorcycle incident

A 44-year-old man with complex psychiatric history and substance abuse was killed in a motorcycle collision while driving unlicensed and under the influence of methylamphetamine. A 92-year-old driver, disoriented after b…

psychiatryaddiction medicinesystemdelaymethamphetamine
SAaged care2020-07-09

Coroner's Finding: HANSLOW Walter Robert

75y · Male·bilateral subdural haematoma due to fall

Walter Robert Hanslow, a 75-year-old man with Parkinson's disease, Alzheimer's disease, and significant mobility limitations, sustained a fall at a nursing home on 9 June 2018. He was found on the ground but initially ap…

geriatric medicineemergency medicinedelay
VICaged care2020-07-06

Finding into death of Irene Florence Curran

79y · Female·Ischaemic bowel in the setting of cardiomegaly, pneumonia and chronic renal fail…

A 79-year-old woman died from ischaemic bowel in the setting of cardiomegaly, pneumonia and chronic renal failure, four days after discharge from hospital following a hysterectomy for endometrial cancer. Key clinical les…

gynaecologygeneral practicecommunicationsystemoxycodone
VIChospital2020-07-02

Finding into death of Cai Wheeler-Trow

0y · Male·Head injury in the setting of labour

Baby Cai Wheeler-Trow was born at 36 weeks and 2 days following a failed instrumental delivery and emergency caesarean section. He developed a skull fracture and subgaleal haemorrhage, presenting with clinical deteriorat…

obstetricspaediatricsdiagnosticcommunication
VIChospital2020-07-02

Finding into death of Craig Vincent Douthie

52y · Male·C2, C3, C4 spinal injury sustained from a fall secondary to seizures

A 52-year-old man with cerebral palsy, epilepsy, and intellectual disability living in disability accommodation fell in the bathroom after a seizure and sustained cervical spine fractures (C2-C3-C4). He was admitted to h…

emergency medicineneurosurgerydelaycommunicationlevetiracetam
VIChospital2020-07-01

Finding into death of Baby M

3y · Male·Hypoxic ischaemic encephalopathy complicating drowning

A 3-year-old boy drowned in a home swimming pool after the pool gate failed to latch properly due to wear and lack of maintenance. The gate did not comply with Australian Standards requiring self-closing and self-latchin…

emergency medicineintensive caresystemdelay
TAShospital2020-06-30

Coroner's Finding: Shrimpton, Dallas Brooks

54y · Male·carbon monoxide asphyxia

Dallas Brooks Shrimpton, a 54-year-old man with severe alcohol dependence, chronic depression, and multiple previous suicide attempts, died by carbon monoxide asphyxiation. He presented to Royal Hobart Hospital ED on 16 …

psychiatryemergency medicinecommunicationsystemalcohol

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