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NSWmental health2019-11-22

Inquest into the death of David Dungay

29y · Male·cardiac arrhythmia

David Dungay, a 29-year-old Aboriginal man with chronic schizophrenia, type 1 diabetes, and obesity, died on 29 December 2015 in Long Bay Hospital's Mental Health Unit while in custody. The immediate trigger was his refu…

psychiatryemergency medicineproceduralcommunicationmidazolam
NSWhospital2019-11-21

Inquest into the death of Ross MARTIN

56y · Male·acute pentobarbitone toxicity

Ross Martin, a 56-year-old man with a long history of depression, died from acute pentobarbitone (Nembutal) toxicity obtained online, combined with toxic levels of zopiclone, less than two weeks after premature discharge…

psychiatrygeneral practicediagnosticcommunicationpentobarbitone
SA2019-11-14

Coroner's Finding: SINGH Heidi Eileen Roseanne

14y · Female·electrocution

Heidi Singh was a 14-year-old Aboriginal girl who died by electrocution at a railway pylon on 21 August 2014. She had suffered from foetal alcohol spectrum disorder since early childhood, experienced multiple losses (par…

paediatricspsychiatrysystemcommunicationquetiapine
WA2019-11-13

Inquest into the Death of Bret Lindsay CAPPER

43y · Male·bronchopneumonia and brain swelling following ligature compression of the neck (…

Bret Lindsay Capper, 43-year-old male remanded in custody at Hakea Prison, Western Australia, died on 14 January 2016 from bronchopneumonia and brain swelling following ligature asphyxiation by hanging. He had antisocial…

psychiatrypsychologysystemcommunicationheroin
VIChospital2019-11-11

Finding into death of Finn Moser

1y · Male·Head injury in the setting of labour

Finn Moser was a one-day-old neonate who died from head injury sustained during labour and delivery at the Royal Women's Hospital. He was born to a mother with dichorionic diamniotic twins, induced at 36 weeks due to pre…

obstetricsneonatologydiagnosticcommunicationprostaglandin gel
NSW2019-11-08

Redacted findings in the joint inquest into deaths arising at music festivals including annexures - 8 November 2019

[18, 21, 23, 19, 22, 19]y · ["male", "female", "male", "male", "male", "female"]·MDMA toxicity (one case mixed MDMA and cocaine toxicity)

This inquest examined six deaths from MDMA toxicity after electronic dance music festivals in NSW between December 2017 and January 2019: Hoang Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), …

emergency medicineintensive carecommunicationproceduralMDMA
NSW2019-11-08

Inquest into the death of six patrons of NSW music festivals

Unknown·MDMA toxicity (3,4-methylenedioxymethylamphetamine toxicity) in each case

Six young people died at NSW music festivals between December 2017 and January 2019 after consuming MDMA (ecstasy) at toxic levels. Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), Joshua Tam (…

emergency medicinetoxicologycommunicationsystemMDMA
ACThospital2019-11-06

Inquest into death of THEADORA ZAAL

75y · Female·cardiac arrest in the context of aortic stenosis (moderate to severe), coronary …

A 75-year-old woman with significant cardiac history (aortic stenosis, coronary artery disease, left ventricular hypertrophy) underwent elective ankle ulcer debridement surgery. She developed refractory hypotension post-…

anaesthesiasurgerydiagnosticsystem
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
VICcommunity2019-10-30

Finding into death of Sanaya Sahib

1y · Female·Suffocation

Sanaya Sahib, age 14 months, died from suffocation on 9 April 2016. Her mother, Sofina Nikat, deliberately suffocated her and left her body in Darebin Creek. Ms Nikat was experiencing significant social isolation, family…

obstetricspsychiatrysystemdelaymethamphetamine
NSW2019-10-25

Inquest into the death of R N

58y · Male·asphyxiation by ligature

A 58-year-old Cambodian male with basic English skills died by suicide in prison after 7 days in custody on remand for assault. Critical failures in the reception screening process included: incomplete identification and…

psychiatrycorrectional healthcommunicationsystem
SAcommunity, workplace2019-10-23

Coroner's Finding: Murray, Erin Paige and Patterson, Amy Jean

Female·pentobarbitone toxicity

Two veterinary-associated women (a veterinary student and a practicing veterinarian) died from pentobarbitone toxicity via ingestion, with evidence of intentional self-harm. The coroner identified that both women had acc…

veterinary medicinepsychiatrysystemdelaypentobarbitone
QLDcommunity2019-10-18

Hunt, Thomas and Kim, Youngeun

Unknown·drowning (Thomas Hunt); drowning/immersion with head injury (Youngeun Kim)

Two young international visitors died by drowning at Josephine Falls in Queensland's wet tropics, separated by two years. Both were swept away by rapidly rising floodwaters in Bottom Pool after heavy rainfall in the Moun…

emergency medicineintensive carecommunicationdelay
TAShospital2019-10-17

Coroner's Finding: Davies, Eva Fay

87y · Female·left frontal temporal subdural haematoma following closed head injury sustained …

An 87-year-old woman on irreversible anticoagulation suffered a subdural haematoma from a fall. She presented to a community hospital lucid with stable vitals. A CT scan confirmed acute subdural haematoma. The neurosurgi…

neurosurgeryemergency medicinecommunicationdiagnostic
VIC2019-10-16

Finding into death of FDS

34y · Male·Mixed drug toxicity

FDS, a 34-year-old male recently released from prison, died from mixed drug toxicity after injecting heroin in a public toilet. He had a long-standing complex drug history and relapsed shortly after release despite parol…

general practiceforensic medicinecommunicationdelayheroin
TAS2019-10-11

Coroner's Finding: Benneworth, Anthony John

67y · Male·Drowning

Anthony Benneworth, aged 67, drowned following a boating accident at Ansons Bay, Tasmania. The vessel capsized after taking on water through poorly maintained inspection covers and unplugged drain holes in the outboard m…

systemdelay
NSW2019-10-11

Inquest into the death of Kim Mackell

64y · Male·Unknown

Kim Mackell, a 64-year-old artist living in the Blue Mountains, disappeared on 18 December 2016 and was found deceased in bushland in April 2017. The cause and manner of death remain unknown; he likely fell from a cliff …

communicationsystem
VICcommunity2019-10-09

Finding into death of Michael Travis Kidd

35y · Male·Clozapine toxicity

A 35-year-old Aboriginal man with schizophrenia and alcohol use disorder died from clozapine toxicity while residing at a non-clinical peer recovery facility. He presented with psychiatric distress on 10 December 2016, r…

psychiatryforensic medicinecommunicationsystemclozapine
NSW2019-10-04

Inquest into the death of Caitlyn FISCHER

22y · Female·blunt force head injuries

Caitlyn Fischer, 22, died from blunt force head injuries after suffering an accidental fall at fence 2 during the cross country phase of a CCI one-star eventing competition at Sydney International Horse Trials on 30 Apri…

emergency medicineparamedicinesystemdelay
NSWcommunity2019-10-04

Inquest into the death of Olivia INGLIS

27y · Female·chest injuries

Olivia Inglis, 27, died from chest injuries sustained in a fall whilst competing in the cross country phase of eventing at the 2016 Scone Horse Trials. She successfully negotiated fence 8A but fell at fence 8B. The coron…

emergency medicineparamedicinesystemcommunication

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