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NThome2018-07-25

Inquest into the death of Paula Schubert

53y · Female·self-inflicted hanging

Paula Schubert, a 53-year-old with schizophreniform psychosis, died by hanging after experiencing workplace stress and abandonment by mental health services. Her employer initiated a demotion process despite her known me…

psychiatrygeneral practicecommunicationsystemrisperidone
TAShome2018-07-25

Coroner's Finding: KW

55y · Male·Combined effects of mixed drug (alcohol and promethazine) toxicity and environme…

A 55-year-old man with alcohol dependency died from combined alcohol and promethazine toxicity with heat exposure. He spent 4-5 hours sunbaking in high temperatures (exceeding 30°C) while heavily intoxicated and sedated …

general practiceemergency medicinesystemdelayalcohol
QLDcommunity2018-07-24

Thwaites, Andrew John

44y · Male·Carbon monoxide toxicity causing loss of consciousness and fatal drowning

A 44-year-old experienced recreational scuba diver, Andrew Thwaites, died during a dive on 10 August 2016 at Cherubs Cave, Moreton Bay, Queensland. He inhaled compressed air containing dangerously high levels of carbon m…

diving medicinehyperbaric medicinesystemmaintenance
SAhospital2018-07-19

Coroner's Finding: ROSS Chrystal Jessica

24y · Female·hypoxic brain injury secondary to hanging

Chrystal Ross, a 24-year-old woman, died by hanging in hospital in January 2015 after a catastrophic chain of communication failures and care coordination errors. She had been admitted to Mount Barker Hospital for anxiet…

psychiatrygeneral practicecommunicationdiagnosticfluvoxamine
TAShome2018-07-13

Coroner's Finding: Mackozdi, Janet Lois

77y · Female·hypothermia from environmental cold exposure with contributing factors of advanc…

Mrs Janet Mackozdi, aged 77, died from hypothermia in an uninsulated shipping container at Mount Lloyd, Tasmania, on 23-24 July 2010. She had advanced Alzheimer's dementia and required 24-hour care. The coroner found her…

geriatric medicinegeneral practicesystemcommunication
NSW2018-07-13

Inquest into the death of Fenika Junior Tautuliu Fenika (Junior Fenika)

24y · Male·Massive blood loss caused by incised wounds of left upper extremity

A 24-year-old man with schizophrenia and psychotic symptoms died from massive blood loss after self-inflicted wrist lacerations in prison custody. He called for help twice via the cell alarm system at 9:17pm and 9:23pm, …

psychiatryemergency medicinecommunicationsystemamisulpride
NSWhospital2018-07-13

Inquest into the death of Leonard Bartholomeusz

73y · Male·Consequences of myocardial infarction with coronary artery atherosclerotic disea…

Leonard Bartholomeusz, aged 73, died of myocardial rupture on 6 May 2013, six days after hip fracture surgery. He suffered a fall on 30 April 2013 following which ECG testing revealed cardiac abnormality. A first ECG at …

emergency medicineorthopaedic surgerysystemcommunicationfentanyl
SAhospital2018-07-12

Coroner's Finding: MITCHELL Wayne Brian

49y · Male·ischaemic heart disease with coronary artery thrombosis (left main stem coronary…

Wayne Mitchell, a 49-year-old man, presented to a clinic with acute chest pain radiating to his jaw, accompanied by dizziness, diaphoresis, and dyspnoea. His symptoms resolved before ambulance arrival. The paramedics per…

cardiologyemergency medicinediagnosticcommunication
VIChome2018-07-10

Finding into death of Pelelini Sooula

50y · Female·haemorrhagic shock and stab wounds to the back, chest and abdomen

A 50-year-old woman of Samoan descent was fatally stabbed by her ex-partner after leaving a violent relationship. She had sustained prior injuries including stab wounds on 26 December 2016 but did not report to police. D…

forensic medicineemergency medicinesystemdelay
QLD2018-07-09

Maisel, Bradford Zaiser – Non-inquest findings

50y · Male·Fatal injuries sustained as a consequence of a helicopter colliding with the oce…

A 50-year-old private pilot died when his Robinson R22 helicopter collided with the ocean near Cape Tribulation, Queensland. Mr Maisel was qualified only for daylight visual flight rules (VFR) operations but departed Coo…

proceduralsystem
QLDhospital2018-07-09

AD - Non-inquest findings

75y · Male·Multi-organ failure secondary to cardiogenic shock and anterior myocardial infar…

A 75-year-old man presented to a tertiary hospital ED with acute anterior STEMI but diagnosis was delayed by approximately 10 hours. The first hospital ECG at 6:47am showed diagnostic ST elevation but was not recognised …

emergency medicinecardiologydiagnosticcommunicationmorphine
TAShome2018-07-06

Coroner's Finding: Godley, David Geoffrey

30y · Male·Exsanguination due to self-inflicted multiple stab and incised wounds

David Geoffrey Godley, aged 30, died from exsanguination due to self-inflicted multiple stab and incised wounds to his neck, chest, and head on 24 April 2016 in Tasmania. He had a long history of psychosis and depression…

psychiatryemergency medicinedelaymethamphetamine
NSW2018-07-06

Inquest into the death of Geoffrey Richardson

Male·multiple injuries sustained in a motor vehicle collision

Sergeant Geoffrey Richardson, an 18-year veteran NSW police officer, died in a single-vehicle collision on 5 March 2016 while responding to assist with a vehicle pursuit. His vehicle failed to negotiate a sweeping bend o…

systemcommunication
NSWhome2018-07-06

Inquest into the death of Miata Jibba

9y · Female·complications of thermal injury

A 9-year-old child died from severe thermal injuries sustained in a house fire. The property had non-functional smoke alarms that the property management company knew about but failed to remedy or report to the landlord.…

intensive careplastic and reconstructive surgerycommunicationsystem
NSWhospital2018-06-29

Inquest into the death of Aidan Mara

3y · Male·Influenza A infection (Type H3N2)

Aidan Mara, a 3-year-old boy with influenza A pneumonia and hyponatraemia, collapsed and died from cardiovascular failure on hospital day 3. Critical clinical lessons include: (1) distinguishing SIADH from dehydration ea…

paediatricsemergency medicinediagnosticcommunicationcefotaxime
ACThospital2018-06-28

AN INQUEST INTO THE DEATH OFJOSEPH YATRAS

52y · Male·Left chest cavity and abdominal cavity haemorrhage due to multiple rib fractures…

A 52-year-old man died from massive internal bleeding (left chest and abdominal cavity haemorrhage) following a motorcycle accident with multiple rib fractures and splenic laceration. He initially appeared to recover wit…

trauma surgeryintensive carediagnosticdelaycannabis
QLD2018-06-28

Hamilton, Blair Andrew

54y · Male·Extensive burns due to detonation of LPG gas cylinder

A 54-year-old man with chronic severe depression, grief from his wife's sudden death, severe debilitating skin condition, and alcohol dependence called emergency services on 12 December 2015, warning them not to approach…

psychiatrygeneral practiceproceduralcommunicationvenlafaxine
WAhome2018-06-27

Inquest into the Death of Brook Damian CAIN

39y · Male·ligature compression of the neck (hanging)

A 39-year-old man with schizoaffective disorder and substance abuse died by suicide following arrest for criminal damage. While treated under a Community Treatment Order, he had poor medication compliance and ongoing dru…

psychiatryemergency medicinecommunicationsystemquetiapine
WAhospital2018-06-25

Inquest into the Death of LCTM

0y · Male·complications of head injury

A premature newborn died from severe head injuries inflicted deliberately by his teenage father in hospital on 15 February 2014. The father had a well-documented history of violence, substance abuse, criminality and had …

neonatologypaediatricscommunicationsystem
NSWhospital2018-06-22

Inquest into the death of Jasmine Chiang

0y · Female·Hypoxia resulting from primary idiopathic pulmonary hypertension of the newborn …

Jasmine Chiang died at 7 hours of age from primary idiopathic pulmonary hypertension of the newborn (PPHN), probably complicated by pulmonary haemorrhage. She presented with classic PPHN signs (harlequin appearance, diff…

neonatologypaediatricsdelaypethidine

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