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VIChospital2019-02-07

Finding into death of JP

39y · Male·septicaemia following self-administered intravenous injection of faeces

A 39-year-old Aboriginal man with schizophrenia, personality disorder, and substance dependence died from septicaemia after self-injecting faeces into his vein while an involuntary mental health patient. He obtained a sy…

psychiatryinfectious diseasessystemdelaypaliperidone
WAcommunity2019-02-06

Inquest into the Death of Torran Jake THOMAS

15y · Male·Multiple organ failure associated with hyperthermia (heat stroke)

A 15-year-old rugby league player died from heat stroke during training on an extremely hot Perth summer evening (44.4°C). The coaching staff appropriately applied NRL heat guidelines in deciding to proceed with modified…

emergency medicineintensive carediagnosticdelay
VICaged care2019-02-04

Finding into death of Margaret Elizabeth Barton

83y · Female·Pneumonia complicating rib and pelvic fractures sustained in the setting of mult…

Margaret Barton, 83, died of pneumonia complicating rib and pelvic fractures from multiple falls. Critical clinical lessons: (1) The Oxazepam regimen directly contributed to her death. Dr C. tripled her dose from 15mg to…

general practicegeriatric medicinemedicationcommunicationoxazepam
VICcommunity2019-01-31

Finding into death of Pauline Mary Riordan

61y · Female·injuries sustained in a motor vehicle collision as a passenger

A 61-year-old woman died from hypovolaemic shock and cardiac arrest following a motor vehicle collision in rural Victoria. She was trapped in her vehicle for approximately 90 minutes with severe crush injuries and lower …

emergency medicinetrauma surgerydelaymorphine
WAcommunity2019-01-29

Inquest into the Death of Glenn William STRICKLAND

43y · Male·Complications of neck injury; specifically extensive brainstem infarction second…

Glenn William Strickland, an experienced Harley Davidson rider, died from brainstem infarction following severe cervical spinal injury sustained in a motorcycle crash on Julimar Road, Western Australia. He failed to nego…

emergency medicinetrauma surgerysystemdelay
VIChospital2019-01-24

Finding into death of Bryan Lindsay Cleeman

86y · Male·Complications post laparoscopic cholecystectomy

86-year-old man with acute gangrenous perforated cholecystitis underwent laparoscopic cholecystectomy on 2 October 2015, forty-two hours after admission. Severe bleeding from hepatic arterial branches required conversion…

general surgeryanaesthesiadelayasasantin
NTPodcast2019-01-16

Inquest into the death of Jason Challis

25y · Male·Gunshot wound to the head

Jason Walter Challis, a 25-year-old rifleman with only 10 months of Defence Force training, was fatally shot in the head during an urban operations live fire exercise at Mount Bundey on 10 May 2017. He was positioned beh…

paramedicineoccupational and environmental healthsystemcommunication
VIChome2019-01-08

Finding into death of Fiona Kellie Burke

32y · Female·hanging

Fiona Burke, aged 32, died by hanging on 17 March 2017 following a prolonged history of family violence in her relationship with Darren Mather. The death occurred in a context of escalating intimate partner violence, alc…

paediatricspsychiatrycommunicationsystemalcohol
TASmental health2019-01-04

Coroner's Finding: Roberts, Nigel Douglas

55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…

Nigel Douglas Roberts, a 55-year-old man with chronic schizophrenia, COPD, and cardiomyopathy, died from cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and olanzapine) in the presence of adv…

psychiatryemergency medicinemedicationdiagnosticclozapine
VIChome2019

Finding into death of Rachel Naomi Mihail

36y · Female·Nicotine toxicity

Rachel Mihail, a 36-year-old with a complex psychiatric history including PTSD, depression, anxiety, and agoraphobia, ingested liquid nicotine at home on 22 November 2017 after calling mental health triage expressing sui…

psychiatrygeneral practicecommunicationsystemnicotine
WA2018-12-27

Inquest into the Death of Mohammad Nasim NAJAFI

24y · Male·seizure (epileptic)

Mohammad Nasim Najafi, a 24-year-old Afghan detainee with well-controlled epilepsy, died from a seizure after missing multiple doses of carbamazepine in the days preceding his death. He was held in immigration detention …

neurologygeneral practicesystemdelaycarbamazepine
ACThome2018-12-20

Inquest into the death of Lesley Kaye Hasleby

61y · Female·respiratory failure consistent with end-stage chronic obstructive airways disord…

A 61-year-old woman with chronic obstructive airways disease, liver disease, depression, and alcohol dependence died from respiratory failure. Her general practitioner prescribed a contraindicated combination of central …

general practicerespiratory medicinediagnosticcommunicationdosulepin
QLDcommunity2018-12-19

Simon, Darrell Gene

46y · Male·Hanging

Darrell Gene Simon, a 46-year-old male, disappeared while on a bicycle ride in November 2014 and was found deceased on his property 18 months later. He died by hanging in the context of severe financial distress, facing …

systemdelay
QLDaged care2018-12-19

Simons, Kathleen

96y · Female·Pseudomonas aeruginosa sepsis secondary to infected leg ulcers, complicated by m…

A 96-year-old woman with diabetes, dementia and a chronic blistering skin condition developed progressively worsening leg ulcers with exposed tendons while resident in an aged care facility. Despite multiple medical revi…

geriatric medicinegeneral practicediagnosticcommunicationcefalexin
NSWmental health2018-12-19

Inquest into the death of R R

38y · Female·neck compression (hanging)

RR, a 38-year-old woman with complex mental health history including PTSD, substance use disorder, and borderline personality traits, was admitted to Bloomfield Hospital on 12 April 2015 following an overdose with stated…

psychiatryemergency medicinecommunicationsystem
VICcommunity2018-12-18

Finding into death of LF M

52y · Male·Multiple injuries sustained in a motor vehicle incident (driver) in a man with a…

A 52-year-old man with epilepsy died in a motor vehicle collision when his car struck a parked truck at high speed with no evidence of braking. Witness accounts and collision reconstruction suggested he experienced a sei…

neurologycardiologycommunicationsystemtopiramate
TAShome2018-12-17

Coroner's Finding: Pitchford, Rhiannon Pearl Vanessa

0y · Female·Sudden infant death whilst bed-sharing with risk factors including unsafe sleepi…

A 55-day-old infant died in an unsafe bed-sharing environment with her sedated mother while her father, intoxicated by intravenous morphine and methamphetamine, remained nearby. The autopsy revealed no obvious cause, but…

paediatricsforensic medicinesystemdelaymorphine
NSWhospital2018-12-17

Inquest into the death of Jarrod Wright

42y · Male·Cardiac arrest following hypoxic ischaemic encephalopathy, likely due to E.coli …

Jarrod Wright, a 42-year-old man admitted with cellulitis, developed sepsis-related acute respiratory distress syndrome (ARDS) requiring ICU care with non-invasive ventilation. Critical failures occurred in managing his …

intensive careinfectious diseasescommunicationsystemmeropenem
TASaged care2018-12-10

Coroner's Finding: McKenzie, Alan John

92y · Male·heart failure secondary to ischaemic heart disease/arrythmia aggravated by a fal…

A 92-year-old man with dementia, Alzheimer's disease and COPD died following a fall from a defective princess chair in aged care. The chair's right armrest had a worn spring mechanism that failed to lock properly, allowi…

geriatric medicineneurosurgerysystemdelay
WAhome2018-12-06

Inquest into the Death of Mark Leslie SACH

27y · Male·combined drug toxicity (U-47700 and etizolam)

Mark Sach, aged 27, died from combined drug toxicity involving U-47700 (a synthetic opioid 7.5 times more potent than morphine) and etizolam (a benzodiazepine 10 times more potent than diazepam), obtained via internet pu…

pain medicinegeneral practicecommunicationdelayu-47700

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