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TAShospital2019-08-21

Coroner's Finding: Golus, Peter

65y · Male·escherichia coli urosepsis

Dr G., a 65-year-old psychologist, died from escherichia coli urosepsis following pyeloscopic kidney stone extraction. Post-operative fever developed within 2 hours of surgery. By 2:00am, clinical evidence of septic shoc…

urologyanaesthesiadelaysystemondansetron
WA2019-08-20

Inquest into the Death of Judy Sonia BOLTON

44y · Female·acute myocardial infarction due to coronary thrombosis

A 44-year-old Aboriginal woman died from acute myocardial infarction (heart attack) due to coronary thrombosis while in custody at Bandyup Women's Prison in Western Australia. She had multiple cardiovascular risk factors…

cardiologyemergency medicinediagnosticsystemmetoprolol
SAhome2019-08-14

Coroner's Finding: KUSKOFF Alexander Peter

50y · Male·gunshot wounds to chest and abdomen

Alexander Kuskoff, aged 50, was fatally shot by STAR Group officer DA on 16 September 2015 following a mental health crisis. Kuskoff displayed florid psychotic symptoms including paranoid delusions, was heavily armed, an…

psychiatryemergency medicinecommunicationsystem
NT2019-08-09

Inquest into the death of Robin Riley, Thomas Turpin, Fabian Andrews, Cassandra Martin

Blunt force trauma from motor vehicle accident (four deceased: head injuries in …

Four people died in a single vehicle rollover on Kakadu Highway, NT. The driver (Robin Riley, 46) and three unrestrained passengers (Thomas Turpin, 39; Cassandra Martin, 32; Fabian Andrews, 45) were killed when their veh…

emergency medicineretrieval medicinesystemdelayalcohol
NSWhospital2019-08-07

Inquest into the death of Pauline KESSELL

53y · Female·multiple organ failure as a result of septic shock

Pauline Kessell, aged 53, died from septic shock caused by overwhelming sepsis following endoscopic pyeloscopy with laser lithotripsy for a 5cm infected staghorn calculus on 12 August 2015. Critical clinical lessons: (1)…

urologyanaesthesiadiagnosticproceduralgentamicin
QLDcommunity2019-08-02

Ms D - Non-inquest findings

47y · Female·Overdose of hydromorphone

A 47-year-old woman died from an intentional overdose of prescribed hydromorphone while residing at a domestic violence refuge. She had a history of depression, previous suicide attempts, and was in crisis following sepa…

psychiatrygeneral practicediagnosticcommunicationhydromorphone
VIChospital2019-08-01

Finding into death of Tyla Jade Hovenbitzer

18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…

An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…

paediatricsgeneral practicesystemdelaytemazepam
ACThome2019-07-31

Inquest into the death of Cheyse Williams-Empson

3y · Male·unascertained

A 3-month-old boy died with an unascertained cause after being found unresponsive in his bassinet with a blanket covering his mouth and face. His mother had ongoing heroin use throughout pregnancy and postnatally, concea…

neonatologyforensic medicinecommunicationsystemheroin
VICaged care2019-07-31

Finding into death of Hong Tay

63y · Male·Sepsis in a man with complicated peripheral vascular disease

Hong Tay, a 63-year-old man with extensive peripheral vascular disease, diabetes, and prior amputations, died from sepsis in an aged care facility following a cervical spine fracture sustained in a fall. After conservati…

geriatric medicinepalliative carecommunicationsystemfentanyl
VIChospital2019-07-30

Finding into death of Allison Judith Allan

43y · Female·Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxic…

43-year-old woman with epilepsy and depression died from hypoxic ischaemic brain injury after ingesting 15g sodium valproate and 750ml vodka. Critical failures occurred across multiple settings: VPIC provided incomplete …

emergency medicineintensive carediagnosticcommunicationsodium valproate
NSWcommunity2019-07-30

Inquest into the death of Dennis Brooks

35y · Male·Unknown

Dennis Brooks, 35, a man with paranoid schizophrenia, disappeared from his Katoomba home on 2 May 2016 after exhibiting signs of psychotic relapse. Although his sister reported him missing on 4 May, a coordinated land se…

psychiatryforensic medicinecommunicationsystem
NSWhospital2019-07-29

Inquest into the death of Naomi Williams

27y · Female·Septicaemia secondary to Neisseria meningitides infection

Naomi Williams, a 27-year-old Wiradjuri woman, died from meningococcal septicaemia on 1 January 2016. She presented to Tumut Hospital in the early hours with generalised aches and pains while pregnant. Despite vital sign…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
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
NSWcommunity2019-07-25

Inquest into the death of Xavier BURKE

15y · Male·multiple injuries sustained in head-on collision with B-double truck during poli…

Xavier Burke, a 15-year-old without a driver's license, fatally collided with a B-double while driving his father's stolen utility during a 29-minute police pursuit covering 59.5 km. The pursuit was initiated based on su…

forensic medicineemergency medicinediagnosticcommunication
QLDhospital2019-07-24

Mr P - Non-inquest findings

47y · Male·Pulmonary thrombo-embolism secondary to deep vein thrombosis in setting of morbi…

A 47-year-old man with morbid obesity presented with respiratory failure, productive cough, and calf swelling. His GP appropriately suspected both pneumonia and pulmonary embolism (PE), requesting urgent CTPA. At Townsvi…

intensive careemergency medicinediagnosticcommunicationheparin
NSWhospital2019-07-22

Inquest into the death of Nicholas Wells

24y · Male·Peritonitis secondary to a perforation of the small bowel

Nicholas Wells, a 24-year-old man, died from peritonitis secondary to small bowel perforation sustained in a motor vehicle accident. Although he was suspected of having a bowel injury at 11am on admission, he was placed …

emergency medicinesurgerydiagnosticcommunicationmethamphetamine
VIC2019-07-17

Finding into death of Fiona Warzywoda

33y · Female·Stab wounds to the chest (tension hemopneumothorax resulting from stab wounds)

A 33-year-old woman was fatally stabbed by her separated de facto partner following a 18-year relationship marked by escalating family violence. Multiple agencies had contact with the victim in the weeks before her death…

paediatricspsychiatrydiagnosticcommunication
QLDaged care2019-07-12

Fenech, George - Non-inquest findings

89y · Male·Congestive heart failure due to or as a consequence of ischaemic cardiomyopathy

George Fenech, 89, died of ischaemic cardiomyopathy complicated by congestive heart failure after a fall at a nursing home. He suffered a cervical spine injury (C1-C2 subluxation) and head laceration during an unwitnesse…

geriatric medicineemergency medicinecommunicationdelaywarfarin
WA2019-07-11

Inquest into the Death of Annabel NICOL

50y · Female·ligature compression of the neck (hanging)

Annabel Nicol, a 50-year-old woman, died by ligature compression of the neck (hanging) in Bandyup Women's Prison on 15 June 2015. She was a remand prisoner with chronic alcoholism, depression, and suicidal ideation who h…

psychiatrycorrectional healthsystemdelaymirtazapine
WAhospital2019-07-09

Inquest into the Death of Troy Michael CONLEY

45y · Male·severe chronic obstructive pulmonary disease

Troy Michael Conley, aged 45, died from severe chronic obstructive pulmonary disease (COPD) while imprisoned. He had developed progressive lung disease from occupational exposure to gyprock dust, intravenous drug use (ta…

respiratory medicinegeneral medicinedelaymethadone

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