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QLDhome2019-05-16

SW - Non-inquest findings

26y · Female·Multiple sharp force injuries of limbs, trunk and head; alcohol intoxication

SW, a 26-year-old Aboriginal woman, died from multiple sharp force injuries sustained in a violent assault by her intimate partner IN after a prolonged drinking session. At the time of death, SW was subject to a domestic…

systemdelayalcohol
SA2019-05-14

Coroner's Finding: SFYRIS Michael

50y · Male·carcinomatosis due to metastatic, poorly differentiated renal cell carcinoma unc…

Michael Sfyris, a 50-year-old prisoner, died of metastatic renal cell carcinoma in April 2016. A CT scan performed in September 2015 revealed an adrenal lesion but the radiology report was misfiled and not reviewed for 2…

oncologyradiologysystemdelaypazopanib
NSWhospital2019-05-14

Inquest into the death of Shaun BELL

4y · Male·Peritoneal sepsis caused by a perforated duodenal ulcer

A 4-year-old boy with significant global developmental delay and non-verbal communication died from peritoneal sepsis caused by a perforated duodenal ulcer. Presentation included lethargy, poor oral intake, low haemoglob…

emergency medicinepaediatricsdiagnosticcommunication
WAhospital2019-05-13

Inquest into the Death of Daniel Josef ADWENT

44y · Male·gunshot wound to abdomen

A 44-year-old male died from a gunshot wound to the abdomen sustained during a police response to a domestic violence incident. He became aggressive, wielded a knife, and lunged at police after Taser and pepper spray fai…

emergency medicinegeneral surgerycommunicationdelay
NSWPodcast2019-05-10

Inquest into the deaths of Stephanie Jane KING, Ella-Jane KABEALO and Jacob Matthew KABEALO

Female·Drowning

On 3 April 2017, Stephanie Jane King and her two children, Ella-Jane (aged 11) and Jacob (aged 7), died when their vehicle lost traction on Dulguigan Road, North Tumbulgum, NSW, after flooding from Ex-Tropical Cyclone De…

systemdelay
WA2019-05-09

Inquest into the Death of Khamsani Victor JACKAMARRA (also known as Hajinoor)

36y · Male·Ligature compression of the neck (suicide by hanging)

A 36-year-old Aboriginal man with cluster B personality disorder, substance abuse, and chronic self-harm risk died by ligature suicide in prison 2 hours after admission. He pleaded guilty to arson charges and was remande…

psychiatryforensic medicinecommunicationsystemmethamphetamine
VIChospital2019-05-09

Finding into death of Darren Templeton

51y · Male·pulmonary thromboembolus secondary to left deep vein thrombosis

Darren Templeton, a 51-year-old man with obesity (BMI 31.5), died of pulmonary thromboembolism and left deep vein thrombosis six days after undergoing left knee arthroscopy. Critical clinical lessons: (1) VTE risk assess…

orthopaedic surgeryanaesthesiasystemdiagnosticaspirin
QLD2019-05-08

Malone, Terrence Michael

54y · Male·incised wound to the neck

Terrence Michael Malone, a 54-year-old man with a 20-year history of bipolar affective disorder, PTSD, and alcohol dependence, died by suicide in Brisbane Correctional Centre on 8 November 2014, three days after re-incar…

psychiatryemergency medicinediagnosticcommunicationalcohol
QLD2019-05-08

Appleton, Garry Ronald

48y · Male·Hypovolaemic shock due to incised wounds to the arms; other significant conditio…

Garry Ronald Appleton, a 48-year-old Indigenous man with schizophrenia, emphysema, and coronary disease, died from hypovolaemic shock after cutting his forearms with a prison-issue razor blade while in custody at Brisban…

psychiatrypsychologycommunicationsystem
NT2019-05-07

Inquest into the death of Sean Daniel Collins

32y · Male·self-inflicted hanging

Sean Collins, a 32-year-old American chef on a work visa who became imprisoned in the Northern Territory, died by suicide in prison custody. He had multiple unaddressed risk factors: first incarceration, lengthy sentence…

general practicepsychiatrydiagnosticcommunicationsertraline
WA2019-05-02

Inquest into the Death of Fazel CHEGENI NEJAD

34y · Male·ligature compression of the neck

Fazel Chegeni Nejad, a 34-year-old Iranian asylum seeker, died from ligature compression of the neck in the jungle near Christmas Island immigration detention centre on 8 November 2015. He had spent 1,477 days in detenti…

psychiatrygeneral practicesystemcommunicationmirtazapine
VICcommunity2019-04-29

Finding into death of William Willms

63y · Male·Unknown

William Willms disappeared on 23 July 1973 at age 63 after boarding a bus to Lilydale railway station. He had recently self-discharged from psychiatric admission for endogenous depression and suicidal ideation. Despite e…

psychiatrygeneral practicesystemdelay
TAShospital2019-04-18

Coroner's Finding: Davis, Catherine Joy

31y · Female·urosepsis due to acute pyelonephritis

Catherine Joy Davis, a 31-year-old woman with severe lissencephaly, intellectual impairment, epilepsy and cerebral palsy, died from urosepsis due to acute pyelonephritis. She presented to ED with vomiting and constipatio…

emergency medicinegeneral medicinediagnosticdelayoral antibiotics via peg tube
TAShospital2019-04-18

Coroner's Finding: Fulham, Julianne

58y · Female·Ischaemic small bowel due to bowel obstruction most likely due to a combination …

Mrs Fulham, aged 58, died from ischaemic small bowel due to obstruction from adhesions and Crohn's disease recurrence. On 22 November, she presented to GP with two weeks of diarrhoea, vomiting, nausea, and abdominal pain…

general practicegastroenterologydiagnosticcommunication
QLDhome2019-04-17

Davis, John

50y · Male·Hypoxic-ischaemic encephalopathy secondary to choking on food bolus

A 50-year-old man with acquired brain injury and intellectual disability died from hypoxic-ischaemic encephalopathy following aspiration of a food bolus during lunch at his disability care residence. The carer appropriat…

emergency medicineparamedicinediagnosticcommunicationmidazolam
QLDhome2019-04-17

Tran, Lucas

0y · Male·Sudden Infant Death Syndrome (SIDS) Category II

Lucas Tran, a five-month-old infant in family day care, died suddenly on 18 November 2015. Despite resuscitation attempts, he could not be revived. Autopsy found no specific pathology; death was attributed to Sudden Infa…

paediatricsemergency medicinesystemcommunication
TAShospital2019-04-16

Coroner's Finding: Hill, Phillip John

82y · Male·sepsis due to faecal peritonitis due to suture failure of bowel anastomosis foll…

An 82-year-old man died from sepsis due to faecal peritonitis following anastomotic breakdown after right hemi-colectomy for colon cancer. Surgery was appropriate and proceeded without incident. Five days post-operativel…

colorectal surgerygeneral surgerydelayamiodarone
VICcommunity2019-04-16

Finding into death of Sophie Margery Nicholas

27y · Female·Injuries sustained in motor vehicle incident (pedestrian)

Sophie Nicholas, aged 27, died by suicide after being struck by a truck while walking along a road at 1:30am on 15 September 2016. She had longstanding borderline personality disorder (BPD) and alcohol dependency, with f…

psychiatryaddiction medicinecommunicationsystemalcohol
QLDcommunity2019-04-05

Morcombe, Daniel James

13y · Male·Asphyxiation as a consequence of neck compression

Daniel James Morcombe, a 13-year-old boy, disappeared on 7 December 2003 while waiting for a bus at Kiel Mountain Road, Palmwoods. He was abducted by Brett Cowan, a known child sex offender, who falsely offered him a rid…

delaycommunication
QLDhome2019-04-04

Blackmore, Rinabel Tiglao - Non-inquest findings

44y · Female·Head injury sustained when exiting a moving vehicle

A 44-year-old Filipino woman died from head injuries after exiting a moving vehicle travelling at 100 km/h during an episode of domestic violence. Ms Blackmore had reported non-lethal strangulation and threats to police …

forensic medicineparamedicinecommunicationsystem

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