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TAShome2017-12-13

Coroner's Finding: Ross, Ronald Charles

66y · Male·Unable to be determined due to advanced decomposition; coroner noted likely medi…

Ronald Charles Ross, a 66-year-old male with significant vascular disease, hypertension, and hyperlipidaemia, was found deceased in his home in Tasmania after an estimated 4-week period. The cause of death could not be d…

general practicevascular surgerydelay
VIChospital2017-12-13

Finding into death of Lachlan Black

2y · Male·Group A beta Haemolytic Streptococcal septicaemia (invasive Group A Streptococca…

A 2-year-7-month-old boy died of Group A Streptococcal septicaemia after three presentations to hospital over three days. Clinical staff failed to recognise the developing bacterial infection despite objective warning si…

emergency medicinepaediatricsdiagnosticsystemparacetamol
VIChospital2017-12-11

Finding into death of Karen Ann Moore

49y · Female·Bronchopneumonia, hypoxic brain injury, and combined drug toxicity (oxycodone an…

Karen Moore, aged 49, died from bronchopneumonia following hypoxic brain injury caused by combined drug toxicity (oxycodone and diazepam). She was found unconscious at home after an overdose and did not regain consciousn…

general practiceemergency medicinemedicationcommunicationoxycodone
VIChospital2017-12-05

Finding into death of Eric George Fiesley

68y · Male·COMPLICATIONS OF MULTIPLE INJURIES SUSTAINED IN A MOTOR VEHICLE INCIDENT

A 68-year-old experienced motorcyclist died from complications of multiple injuries sustained in a motor vehicle collision on 8 May 2017 when a vehicle driven by an 82-year-old man turned right directly into his path. Th…

emergency medicinetrauma surgerysystemdelay
QLDhospital2017-12-04

Mr AC - Non-inquest findings

76y · Male·Coronary atherosclerosis in the context of obesity, obstructive sleep apnoea, an…

A 76-year-old man with significant comorbidities including severe obstructive sleep apnoea, obesity, aortic stenosis, and ischaemic heart disease died from acute coronary atherosclerosis 36 hours after elective sacroilia…

neurosurgeryanaesthesiadiagnosticcommunicationamiodarone
QLDhospital2017-12-01

Girven, Bianca – Non-inquest findings

22y · Female·Hypoxic-ischaemic encephalopathy due to asphyxia (mechanical asphyxiation by nec…

A 22-year-old woman died from asphyxia following strangulation by her boyfriend with schizophrenia. The boyfriend was under mental health service care at Princess Alexandra Hospital. The coroner found his mental health t…

psychiatryemergency medicinediagnosticcommunicationclozapine
NSWhospital2017-12-01

Inquest into the death of Carey Alexander

13y · Male·borderline myocarditis, most likely due to influenza A virus infection

A 13-year-old previously healthy boy with borderline myocarditis presented to an adult ED with flu-like symptoms, lethargy, dizziness, syncope and inability to walk unaided. Despite these concerning features, he was disc…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
SAmental health2017-11-29

Coroner's Finding: MICHIE Tiffany Jayne.docx

22y · Female·plastic bag asphyxia, possibly contributed to by neck compression

A 22-year-old woman with severe depression and documented suicidal ideation died by plastic bag asphyxiation while detained under a Mental Health Act order in a psychiatric ward. She had explicitly stated plastic bag asp…

psychiatryemergency medicinediagnosticcommunicationmirtazapine
NSW2017-11-28

Inquest into the death of Robert Elan Peihopa

42y · Male·Fatal cardiac arrhythmia

A 42-year-old male with undiagnosed chronic coronary artery disease died of fatal cardiac arrhythmia at an immigration detention centre. Key contributing factors were: ingestion of methamphetamine (toxic levels) in the h…

emergency medicinecardiologycommunicationsystemmethamphetamine
QLDcommunity2017-11-27

Finlayson, Eric Davis

68y · Male·drowning against a background of cardiomegaly and severe coronary artery calcifi…

Eric Finlayson, a 68-year-old UK tourist, died by drowning on 9 October 2012 while snorkelling at Michaelmas Cay on the Great Barrier Reef. He had undiagnosed cardiomegaly and severe coronary atherosclerosis. The coroner…

emergency medicineoccupational and environmental healthsystemcommunication
QLDhospital2017-11-23

Jacobs, Roy Rodney

48y · Male·Coronary artery disease precipitating acute myocardial infarction resulting in c…

Roy Rodney Jacobs, a 48-year-old Aboriginal man with cirrhosis and coronary artery disease, died of acute myocardial infarction at Cherbourg Hospital after presenting three times over 28-30 August 2016 with chest pain an…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
NT2017-11-21

Inquest into the death of Dale Walkinshaw

23y · Male·self-inflicted hanging

Dale Walkinshaw, a 23-year-old male, died by self-inflicted hanging in a police caged vehicle while being transported to hospital for medical clearance following his arrest for drink-driving. He used his bootlace, attach…

emergency medicineintensive caresystemdelayalcohol
VIChospital2017-11-20

Finding into death of Graeme Harold Griffiths

65y · Male·Severe neutropenic sepsis and multi-organ failure secondary to severe mucositis …

A 65-year-old man with stage 3 rectal cancer died from severe neutropenic sepsis and multi-organ failure secondary to probable dihydropyrimidine dehydrogenase (DPD) deficiency when treated with capecitabine chemotherapy.…

oncologyradiation oncologydelaycapecitabine
NSW2017-11-20

Inquest into the death of Glennon Johnstone

87y · Male·Complications of acute subdural haematoma

An 87-year-old prisoner died from complications of acute subdural haematoma sustained in a fall at Kirkconnell Correctional Centre. He fell while walking in the common area and struck his head on metal fittings. Though p…

neurosurgerygeriatric medicinesystemdelay
TASmental health2017-11-17

Coroner's Finding: Smith, Molly Jessie

75y · Female·pyelonephritis and pneumonia

Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …

psychiatrygeneral practicediagnosticdelaycefalexin
SAhospital2017-11-15

Coroner's Finding: BROADWAY Rita Ann

66y · Female·urinary tract infection with contributing hypertensive heart disease, diabetes m…

Rita Ann Broadway, 66, died from urinary tract infection on 2 January 2015, one day after presenting to Modbury Hospital Emergency Department with vaginal pain and signs of infection. She had a long-term indwelling cathe…

emergency medicineinfectious diseasesdiagnosticcommunicationparacetamol/codeine
QLD2017-11-09

Ackerman, James William

25y · Male·Traumatic subarachnoid haemorrhage due to right intracranial internal carotid ar…

A 25-year-old semi-professional rugby league player died from a traumatic subarachnoid haemorrhage following a carotid artery dissection sustained during a tackle in a June 2015 match. The injury mechanism involved a sho…

emergency medicinesports medicinesystemdelay
QLDcommunity2017-11-09

Vance, Jason John

42y · Male·Undetermined

Jason Vance, a 42-year-old man with a history of substance misuse, disappeared in October 2013 after walking into Barakula State Forest near Chinchilla, Queensland. He was last seen by two companions, Megan Pitt and Alex…

delaycommunicationmethamphetamine
NSW2017-11-09

Inquest into the death of David Veech

35y · Male·Fentanyl toxicity

David Veech, aged 35, died of accidental Fentanyl toxicity while residing at Tarlo Intensive Residential Support Service. He extracted Fentanyl from prescribed transdermal patches and injected it intravenously. Despite b…

general practicepsychiatrysystemcommunicationfentanyl
TAShospital2017-11-01

Coroner's Finding: French, Steven John

57y · Male·large volume ischaemic infarct (stroke)

Stephen John French, a 57-year-old with prior stroke (2002) and myocardial infarction (2009), presented with headache, visual disturbance and gait difficulty in May 2013. Imaging at Launceston General Hospital on 30 May …

neurologyradiologydiagnosticcommunicationenoxaparin

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