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NSWhospital2018-02-27

Inquest into the death of Michaela Perrin

26y · Female·sepsis

Michaela Perrin, 26, died from sepsis arising from a post-caesarean wound infection caused by MRSA on 22 October 2014. She presented to the Emergency Department on 20 October with severe pain, tachycardia (125 bpm), and …

obstetricsemergency medicinediagnosticcommunicationceftriaxone
VIChospital2018-02-26

Finding into death of Louis Oliver Tate

13y · Male·Malignant hyperthermia due to a reaction to an anaesthetic agent administered to…

Louis Tate, a 13-year-old with known allergies to cow's milk, raw egg, peanuts and tree nuts, died following anaphylaxis to breakfast provided in hospital. Despite reasonable medical management of the anaphylactic reacti…

paediatricsemergency medicinesystemcommunicationadrenaline
SAcommunity2018-02-23

Finding into death of Alexander Sheng Wei Li

16y · Male·Heat related illness in an individual with enterovirus D68 infection

Alexander Li, a 16-year-old with underlying enterovirus D68 infection, died of heat-related illness during a school bushwalking expedition in remote South Australia in extremely hot conditions (temperatures reaching 39.1…

emergency medicineparamedicinesystemcommunication
QLDhospital2018-02-21

Barichello, Daniele Antony - Non-inquest findings

43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…

A 43-year-old man with a colloid cyst of the third ventricle presenting with progressive headache was admitted for planned endoscopic surgery. Surgery was delayed from Friday to Monday due to unavailability of specialist…

neurosurgeryintensive carediagnosticdelaytramadol
QLD2018-02-16

Cheney, Danny George

Male·Electrocution from electrical induction shock while installing spacers on high-v…

Danny George Cheney, a newly promoted Construction Manager and Stringing Supervisor with John Holland Group, died from electrocution while installing spacers on high-voltage transmission line conductors. Working from a c…

occupational and environmental healthdiagnosticprocedural
NSW2018-02-16

Inquest into the death of Carney Schultz

28y · Female·complications of epilepsy

Carney Schultz, a 28-year-old woman with severe cerebral palsy, hydrocephalus, and epilepsy, died on 21 April 2015 at a group home. She experienced a seizure around 3:20am managed by a disability support worker (DSW) wit…

neurologygeneral practicecommunicationsystemmidazolam
NT2018-02-07

Inquest into the death of Vernon Bonson

31y · Male·Self-inflicted hanging

Vernon Bonson, a 31-year-old Aboriginal man, died by self-inflicted hanging in Darwin Correctional Precinct on 25 August 2016. He was remanded in custody facing sexual assault allegations that appear to have originated f…

systemdelay
QLDmental health2018-02-05

Hitchins, Steven John; Gudge, Shawn Bradley Joseph

53y · Male·Steven Hitchins: plastic bag asphyxiation; Shawn Gudge: hanging

Two inpatient suicides in a Queensland mental health unit highlight systemic failures in environmental hazard management and observation practices. Steven Hitchins (age 53) died by asphyxiation with a plastic bag in 2014…

psychiatryemergency medicinesystemcommunicationrisperidone
VIChome2018-02-01

Finding into death of Devlin Charles Duffy

21y · Male·asphyxia from inhalation of helium

21-year-old Devlin Duffy died from asphyxia due to helium inhalation. He had connective tissue disease causing chronic pain and disability. In May 2016, his GP Dr N. diagnosed moderate depression and prescribed desvenlaf…

general practicepsychiatrycommunicationsystemdesvenlafaxine
TASaged care2018-01-29

Coroner's Finding: Ball, Betty Irene

67y · Female·perforated sigmoid volvulus with peritonitis upon a background of spinocerebella…

Betty Irene Ball, aged 67, died from perforated sigmoid volvulus with peritonitis on 2 February 2016. She had spinocerebellar ataxia and was resident in aged care. She developed constipation from 15 January 2016, but med…

general practiceemergency medicinedelaysystemparacetamol
TAScommunity2018-01-25

Coroner's Finding: Lockwood, Shane

45y · Male·Stab wound to the chest, self-inflicted

Shane Lockwood, a 45-year-old man with chronic schizophrenia, died by self-inflicted stab wound in April 2009, approximately two months after discharge from psychiatric hospital on a Community Treatment Order. He was dis…

psychiatrygeneral practicecommunicationsystemclozapine
TAShospital2018-01-23

Coroner's Finding: Mr M

41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…

A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr R.'s failure to diagnose stroke on 7 September and arrange u…

emergency medicineneurologydiagnosticcommunication
SA2018-01-17

Coroner's Finding: COSTI John Steve

39y · Male·neck compression (due to hanging) and plastic bag asphyxia

John Steve Costi, aged 39, died by suicide in Adelaide Remand Centre on 27 November 2013. He fashioned a ligature from bedding strips and hanged himself using an unusual hanging point in his single cell between 4am and 6…

correctional healthpsychologysystemdelay
VIC2018-01-17

Finding into death of John Gale

64y · Male·Aspiration pneumonia in a man with dysphagia and acquired brain injury

John Gale, a 64-year-old man with acquired brain injury and severe intellectual disability living in state care, died from aspiration pneumonia following a fall and pneumonia diagnosis in May 2016. He was transferred bac…

general practicegastroenterologysystemdelay
NThospital2018-01-11

Inquest into the death of Addison Anthony

35y · Male·Active rheumatic pancarditis complicated by pulmonary arterial hypertension, pne…

A 35-year-old Aboriginal man died from rheumatic pancarditis complicated by pulmonary hypertension, pneumonia and unspecified connective tissue disease. He had presented repeatedly to Katherine Hospital with symptoms sug…

emergency medicineintensive carecommunicationdiagnosticdicloxacillin
VICcommunity2018-01-08

Finding into death of Mark Jordan-Hill

46y · Male·Drowning

Mark Jordan-Hill, a 46-year-old experienced ocean paddler, drowned off Torquay, Victoria during a challenging paddle in severe weather conditions (20-35 knot winds, 3-4 metre offshore swells, low tide). He fell from his …

forensic medicineemergency medicinedelay
VICcommunity2018

Finding into death of Konstantinos Eleftheriou-Tragakis

36y · Male·Hanging

A 36-year-old man with schizoaffective disorder, substance use disorder, and previous psychotic episodes was discharged from psychiatric inpatient care after being absent without leave for 72 hours. On 4 June 2017, he co…

psychiatrycommunicationsystemrisperidone
NSWhospital2017-12-22

Inquest into the death of Colin Parker

41y · Male·Complications of blunt force injuries of the head

Colin Parker, aged 41, suffered an unwitnessed fall with head injury while experiencing syncope from atrial fibrillation in early May 2014. He was admitted to Campbelltown Hospital but his serious intracranial pathology …

cardiologyemergency medicinediagnosticcommunicationenoxaparin
QLD2017-12-15

Martin, Christopher Leslie

65y · Male·Spontaneous lethal arrhythmia on a background of cardiomegaly, myocardial fibros…

Christopher Martin, aged 65, died from cardiac arrest during police restraint following a drink-driving detection. He had significant underlying cardiac disease (coronary artery stenosis, myocardial fibrosis, cardiomegal…

cardiologyforensic medicinedelayalcohol
QLDhome2017-12-14

Robertson, Charlie Mark John

19y · Male·Toxic effects of multiple drugs, primarily gammahydroxybutyric acid (GHB), causi…

Charlie Robertson, a 19-year-old university student, died from polydrug toxicity (cocaine, MDMA, and GHB) on 13 June 2015. During the early morning execution of a police search warrant at his home, seven Queensland Polic…

forensic medicinetoxicologydiagnosticcommunicationgammahydroxybutyric acid

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