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VIChome2016-08-02

Finding into death of Stephen Liat Kai Lim

56y · Male·Benzalkonium chloride toxicity

Stephen Lim, aged 56, died from benzalkonium chloride toxicity after deliberately ingesting approximately 2.5 litres of Pine-O-Cleen disinfectant on 25 September 2010. His death occurred from acute lung injury due to asp…

emergency medicinetoxicologycommunicationsystembenzalkonium chloride
VICcommunity2016-06-07

Finding into death of Simon Mark Everill

55y · Male·Complications of right middle cerebral artery infarction

Simon Mark Everill, a 55-year-old man with intellectual disability and epilepsy, suffered a right middle cerebral artery infarction on 3 September 2014 after experiencing two falls during a day service activity. His symp…

general practiceemergency medicinediagnosticcommunicationsimvastatin
VIChospital2016-06-03

Finding into death of Ronak Satyajit Warty

10y · Male·complications of anaphylaxis

Ronak Satyajit Warty, a 10-year-old boy with known milk and nut allergies, died from anaphylaxis after ingesting a coconut drink that was mislabelled and contained undeclared dairy products. Despite his parents' diligenc…

emergency medicinepaediatricsdelaysystemadrenaline
QLDcommunity2016-04-20

Newport, Glenn Richard

38y · Male·cardiac arrest precipitated by dilutional hyponatraemia

A 38-year-old construction worker died from dilutional hyponatraemia after working in extreme heat (>40°C) on a concrete formwork project in rural Queensland. He developed symptoms of heat injury at the worksite and was …

occupational and environmental healthparamedicinediagnosticcommunication
VIChome2016-03-24

Finding into death of Caroline Emily Lovell

36y · Female·Global ischaemic injury following cardiorespiratory arrest in the immediate post…

Caroline Lovell, 36, died from postpartum haemorrhage following home birth of her second child. She had significant risk factors: prior PPH with first child and uterine fibroid, but these were not properly investigated b…

midwiferyobstetricsdiagnosticcommunicationsyntocin
NT2016-03-18

Inquest into the death of Styles Isaac King

30y · Male·traumatic asphyxiation

Styles Isaac King, an Aboriginal man aged 30, died from traumatic asphyxiation following restraint by crowd controllers at a bar in Katherine, Northern Territory. During an altercation, he was held face-down on the floor…

emergency medicineparamedicineproceduralsystemalcohol
VIC2016-02-24

Finding into death of Andrew Hepple Pattison

39y · Male·Positional asphyxia in a setting of intoxication and minor head injury

Mr Andrew Hepple Pattison, a 39-year-old regular patron of the Footscray Club, died from positional asphyxia after falling down stairs while heavily intoxicated. He had consumed approximately 10-12 pots of beer and was a…

emergency medicineforensic medicinecommunicationdelayalcohol
VIChome2016-02-17

Finding into death of Lorraine Mary Bartolome

73y · Female·Exsanguination from ruptured varicose vein right lower leg

A 73-year-old woman died from exsanguination following rupture of a varicose vein on her right lower leg while on anticoagulation therapy (dabigatran) for atrial fibrillation. She called emergency services at 1:22 am on …

emergency medicinecardiologycommunicationsystemdabigatran
QLDhospital2016-02-17

Dickinson, Rick Dudley

55y · Male·Cardiac tamponade due to ruptured aortic dissection (Type A) against a backgroun…

Rick Dickinson, a 55-year-old man, presented to St Andrew's War Memorial Hospital after experiencing severe central chest pain and lower back pain with numbness at the gym. The treating senior doctor failed to adequately…

emergency medicinepathologydiagnosticcommunicationmorphine
NSW2015-10-27

Inquest into the death of Kevin Norris

38y · Male·Combined effects of methylamphetamine toxicity, violent struggle, and positional…

Kevin Norris, 38, died in police custody after methamphetamine intoxication, violent police restraint at McDonald's, and positional asphyxia at Bowral Police Station. He had schizophrenia and was on a Community Treatment…

emergency medicineintensive caredelaycommunicationmethamphetamine
VIChome2015-10-08

Finding into death of Bruce Desmond Andrews

60y · Male·medication overdose

Bruce Andrews, a 60-year-old man with major depression and anxiety, died from medication overdose following relationship breakdown and acute alcohol intoxication. He fell from his porch, called his granddaughter reportin…

psychiatryemergency medicinecommunicationdiagnosticclonazepam
QLD2015-09-22

Martin, James Thomas; Poate, Robert Hugh Frederick; Milosevic, Stjepan Rick

21y · Male·Multiple gunshot wounds deliberately inflicted by member of Afghan National Army

Three Australian soldiers died in an insider attack at Patrol Base Wahab, Afghanistan on 29 August 2012. An Afghan soldier, Hekmatullah, fired approximately 30 rounds killing Sapper James Martin and Private Robert Poate …

paramedicinecommunicationsystem
VICmental health2015-07-08

Finding into death of David Allan D'Angelo

30y · Male·Heroin toxicity

David D'Angelo, a 30-year-old Aboriginal man with schizophrenia and polysubstance dependence, was admitted to The Alfred Psychiatric Unit involuntarily on 24 March 2010 for psychotic relapse. His symptoms improved rapidl…

psychiatryemergency medicinesystemdelayheroin
SA2015-06-24

Coroner's Finding: HARDING-ROOTS Jeremy Godfrey

47y · Male·Toxic effects of phosphine gas

Jeremy Harding-Roots died from phosphine gas toxicity after deliberately exposing himself to the pesticide fumigant aluminium phosphide (Fumitoxin) during a siege at his former girlfriend's residence. Key clinical and pr…

psychiatrygeneral practicediagnosticsystemoxazepam
WAhome2015-06-08

Inquest into the Death of Baby P

0y · Male·intrapartum hypoxia due to placental abruption

A second twin boy was born at home despite medical advice that twin pregnancies require hospital care. The mother, who strongly preferred home birth, disengaged from hospital when her preferences for birth management (va…

obstetricsmidwiferycommunicationdelay
NSWhospital2015-02-13

Inquest into the death of Baby RD

0y · Male·Head injury from non-accidental trauma (forced shaking) occurring on 11 May 2009

Baby R, born at 28 weeks gestation, died of non-accidental head injury sustained on 11 May 2009 when forcefully shaken by a person or persons unknown while in parental care. The 5-month-old presented with cardiorespirato…

paediatricsintensive carediagnosticsystem
QLDhospital2014-08-05

Olive, Thomas (Tom) Andrew

4y · Male·Severe rhabdomyolysis due to LPIN1 gene mutation

Tom Olive, aged 4, died from severe rhabdomyolysis caused by a rare LPIN1 gene mutation. Over 12 months before death, he presented with recurrent episodes of dark urine, muscle pain, and lethargy. Multiple GPs and a paed…

general practiceemergency medicinediagnosticcommunicationsuxamethonium chloride
QLDhome2014-07-25

Petersen, Nicole - Non-inquest findings

19y · Female·Mixed drug toxicity, with morphine (from poppy seeds) and dextromethorphan (from…

Nicole Petersen, aged 19, died from mixed drug toxicity due to consumption of poppy seed tea combined with cough syrup and diazepam. She became unresponsive overnight and was discovered in cardiac arrest around 5:45am. H…

emergency medicinetoxicologydelaysystemmorphine
SAhospital2014-02-14

Coroner's Finding: RYAN John William and WALTON Patricia Dawn

Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…

Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…

anaesthesiaorthopaedic surgerydiagnosticcommunicationmorphine
SAhospital2014-02-05

Coroner's Finding: COOK Eileen Hazel

76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…

Mrs Cook, a 76-year-old woman, died in January 2010 from hospital-acquired pneumonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangerously…

general practiceemergency medicinediagnosticcommunicationintravenous fluids
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