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VIChome2016-10-07

Finding into death of Milica (Mary) Minchev

48y · Female·Combined drug toxicity involving oxycodone, benzodiazepines (diazepam, nordiazep…

A 48-year-old woman with epilepsy, depression, anxiety and documented drug dependence died from combined toxicity of oxycodone, benzodiazepines, amitriptyline and other drugs. Over 12 months pre-death, she obtained medic…

general practicepsychiatrydiagnosticmedicationoxycodone
VIChome2016-10-06

Finding into death of Martha Alice Fraser

0y · Female·Intrapartum hypoxia due to breech delivery with head entrapment and associated c…

Martha Alice Fraser was born on 30 May 2011 following an unplanned home birth in a frank breech presentation. Her mother, Ms Wood, went into spontaneous labour at home but did not reach hospital in time. The delivery inv…

obstetricsneonatologycommunicationdelayadrenaline
WAhome2016-09-30

Inquest into the Death of Janene DEVINE

48y · Female·malnutrition in association with sepsis on a background of end stage multiple sc…

A 48-year-old woman with end-stage multiple sclerosis died from malnutrition and sepsis after her husband, her primary carer, failed to provide adequate nutrition via a PEG tube despite receiving training and instruction…

neurologygastroenterologysystemdelay
TAScommunity2016-09-30

Coroner's Finding: Westbrook, Eden Jayde

15y · Female·asphyxia due to hanging

Eden Jayde Westbrook, a 15-year-old high school student, died by suicide on 17 February 2015. She had experienced depression for some time without formal diagnosis, had a history of self-harm and suicide attempts, and ha…

psychiatrypaediatricssystemdelay
WA2016-09-27

Inquest into the Death of Baby Z

0y · Male·unascertained

Baby Z, born to a serving prisoner on 3 March 2011, died suddenly on 3 April 2011 at Bandyup Women's Prison at one month of age. Despite extensive forensic investigation, the cause of death remained unascertained, though…

obstetricsneonatologycommunicationdelaymethadone
SA2016-09-22

Coroner's Finding: HENEKER Scott Maxwell

36y · Male·Hypoxic ischaemic encephalopathy due to cardiac arrest occurring during restrain…

Scott Maxwell Heneker, aged 36, died from hypoxic ischaemic encephalopathy due to cardiac arrest occurring during physical restraint by a homeowner. The deceased had entered the homeowner's house without permission while…

psychiatryemergency medicinedelaycommunicationmethamphetamine
NThome2016-09-21

Inquest into the death of Wendy Murphy

Female·Wendy Murphy: blunt head and chest trauma; Natalie McCormack: haemorrhage follow…

Two Aboriginal women in Alice Springs died from domestic violence after years of repeated assaults by intimate partners. Wendy Murphy, 36, was beaten to death by Stanley Scrutton after a 10-year history of documented vio…

systemdelayalcohol
QLDhospital2016-09-15

Mr B, a 41 year old indigenous man - Non-inquest findings

41y · Male·Subdural haematoma

A 41-year-old Aboriginal man with excessive alcohol use presented four times to a rural hospital over one month with headaches. His symptoms were attributed to cluster migraine, then alcohol withdrawal syndrome, despite …

emergency medicineneurologydiagnosticcommunicationdiazepam
VIChospital2016-09-15

Finding into death of Bernas Hasibuan

50y · Male·gastrointestinal haemorrhage; haemorrhage from cystic artery post laparoscopic c…

A 50-year-old man died from gastrointestinal haemorrhage involving both a cystic artery and duodenal defect following laparoscopic cholecystectomy. Over five days post-surgery, he developed repeated episodes of hypotensi…

general surgeryintensive carediagnosticcommunication
NSWhome2016-09-14

Inquest into the death of NA

0y · Male·Hypoxic ischaemic encephalopathy (brain damage) sustained during and just after …

A newborn died from hypoxic-ischaemic encephalopathy following a home birth without medical assistance. The mother had significant risk factors: hepatitis C, anaemia, and transverse fetal lie confirmed at 38+ weeks gesta…

general practiceobstetricscommunicationsystem
VIC2016-09-13

Finding into death of Leister John Ross

45y · Male·undetermined in a man in correctional services custody with a chronic history of…

Leister John Ross, a 45-year-old Aboriginal prisoner, died in Port Phillip Prison on 10 July 2014 from an undetermined cause in a man with chronic illicit drug use. Forensic pathology revealed pulmonary oedema, hepatic c…

forensic medicinetoxicologyproceduralsystemmethamphetamine
TAScommunity2016-09-12

Coroner's Finding: Broomhall, Tyler John

23y · Male·intra-cerebral haemorrhage following methylamphetamine use

Tyler John Broomhall, a 23-year-old factory worker, died from intracranial haemorrhage following methylamphetamine use during a football match. He had suffered a prior unreported work-related head injury 4-6 weeks earlie…

emergency medicineintensive carediagnosticdelaymethamphetamine
NSW2016-09-12

Inquest into the death of M

15y · Female·hypoxic brain damage due to multiple drug toxicity

A 15-year-old girl in out-of-home residential care died from accidental overdose of heroin and methylamphetamine (speedballing) in her bedroom while a known drug user was present. She had complex trauma from childhood ab…

emergency medicinetoxicologydelaysystemheroin
WAhospital2016-09-08

Inquest into the Death of Anandakumar SELLAKATHIRKGAMAN

38y · Male·hypoxic brain injury and organ failure following compression of the neck (hangin…

A 38-year-old Sri Lankan asylum seeker died by suicide after being released from immigration detention on a bridging visa. He had documented anxiety and trauma history during detention, managed by psychiatrist Dr A. who …

psychiatryemergency medicinediagnosticcommunicationdiazepam
NSWmental health2016-09-07

Inquest into the death of Miriam MERTEN

Female·traumatic and hypoxic brain injury caused by numerous falls and self-beating of …

Miriam Merten died from traumatic and hypoxic brain injury sustained during 25+ falls while in seclusion in a mental health unit. Critical clinical failures occurred: she was not provided one-to-one observation during th…

psychiatrycommunicationproceduralpsychotropic medications
VICcommunity2016-09-06

Finding into death of Antonio D'Augello

63y · Male·Drowning

Antonio D'Augello, a 63-year-old man with schizophrenia and acquired brain injury, died by drowning in an irrigation channel four days after discharge from emergency care. He had deteriorated after stopping antipsychotic…

psychiatryemergency medicinecommunicationdelayolanzapine
NT2016-09-05

Inquest into the death of Jethro Dhamarrandji-Baker

12y · Male·Head, chest and abdominal injuries sustained when run over by a vehicle

A 12-year-old Aboriginal boy died from head, chest and abdominal injuries when run over by a Toyota Landcruiser during a school carnival 'Troopy Pull' activity. The vehicle was being pulled by students using rope attache…

emergency medicinepathologysystemcommunication
NT2016-09-02

Inquest into the death of Marrianne Munkara

45y · Female·Bronchiectasis

A 45-year-old Aboriginal woman with severe bronchiectasis, COPD, and cor pulmonale died at a sobering-up shelter after police protective custody. She had 15 hospital admissions in 2015 for acute exacerbations related to …

respiratory medicineemergency medicinesystemcommunication
NThospital2016-09-02

Inquest into the death of Christopher Murrungun

53y · Male·Left intra cerebral and left subdural haemorrhage

Christopher Wurrmerli Murrungun, a 53-year-old Aboriginal man, died from intracerebral and subdural haemorrhage at Royal Darwin Hospital on 12 February 2015. He was found intoxicated on a public footpath in Parap, Darwin…

emergency medicineneurologysystemcommunicationalcohol
QLDhospital2016-09-02

Calder, Michael James

33y · Male·Opiate toxicity

A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both slow-release (MS Co…

general medicineemergency medicinemedicationdiagnosticmorphine

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