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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
VIChome2016-02-17

Finding into death of Emmerson Elizabeth Boyle

3y · Female·Drowning

A 3-year-old girl drowned in a home bathtub after her mother briefly left the bathroom to retrieve a towel. The child had recently fallen twice and had a minor head cold but was otherwise healthy. She was found submerged…

systemdelay
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
WAhome2016-02-10

Inquest into the Death of Adrian Marcus WESTLUND

22y · Male·Combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan and op…

Adrian Westlund, a 22-year-old with complex drug-seeking behaviour and polypharmacy addiction, died of combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan). He manipulated multiple GPs by misreprese…

general practiceaddiction medicinediagnosticcommunicationalprazolam
WAhome2016-02-10

Inquest into the Death of Shayne Andrew BERRY

44y · Male·Combined drug effect (oxycodone and benzodiazepines)

A 44-year-old man with a history of heroin addiction registered as a drug addict in 2010 died from combined drug effect involving oxycodone and benzodiazepines. Despite being a registered drug addict, he obtained prescri…

general practicepharmacologysystemcommunicationoxycodone
SAaged care2016-02-08

Coroner's Finding: FORD Marie Janet

84y · Female·acute left subdural haematoma

Marie Janet Ford, 84 years old with dementia, fell from a chair at a residential aged care facility and sustained an acute left subdural haematoma. She was on warfarin for deep vein thrombosis and atrial fibrillation. In…

geriatric medicineemergency medicinecommunicationsystemwarfarin
QLDPodcast2016-02-05

Edwards, Sean Lawrence Guy

26y · Male·Multiple injuries sustained in motor vehicle collision

Sean Edwards, a professional racing driver aged 26, died as a passenger during a coaching session at Queensland Raceway when the vehicle experienced total mechanical brake failure approaching Turn 6 at approximately 165 …

diagnosticsystem
QLDcommunity2016-02-05

Cooper, Paul James - Non-inquest findings

41y · Male·Hanging

Paul Cooper, a 41-year-old man with bipolar disorder, died by hanging in August 2015, eleven days after psychiatric review. He had recently commenced Isotretinoin for severe acne, which coincided with development of para…

psychiatrygeneral practicecommunicationsystemisotretinoin
VICcommunity2016-02-04

Finding into death of Gillian Edie Meagher

29y · Female·compression of the neck

Gillian Edie Meagher, 29, was murdered by Adrian Ernest Bayley in 2012 via compression of the neck during a sexual assault. Bayley was on parole for multiple previous sexual offences and violent crimes when he committed …

systemdelayalcohol
NSWcommunity2016-01-29

Jimmy JAMES - Findings

44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)

Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…

emergency medicineintensive carediagnosticmedicationceftriaxone
SAhome2016-01-28

Coroner's Finding: NAPIER Ebony Simone

0y · Female·Blunt head trauma from multiple deliberate blows inflicted by father

Ebony Napier, aged 4 months, died from blunt head trauma resulting from multiple deliberate blows inflicted by her father Bradley Napier-Tucker over several weeks. A critical failure occurred when the South Australian ch…

paediatricsradiologydiagnosticcommunicationcannabis
VICcommunity2016-01-19

Finding into death of Benjamin Hodgson

29y · Male·Diabetic ketoacidosis

Benjamin Hodgson, a 29-year-old man, presented to his GP on 20 January 2014 with polyuria, polydipsia, difficulty sleeping, fever (38.6°C), and hypertension. The GP diagnosed a urinary tract infection and prescribed anti…

general practicepathologydiagnosticdelaycefalexin
VIChome2016-01-18

Finding into death of Dean Wayne Wright

30y · Male·Mixed drug toxicity (codeine, tramadol, oxazepam, diazepam)

Dean Wright, a 30-year-old man with bipolar disorder, schizophrenia, anxiety and opioid dependence, died from mixed drug toxicity involving codeine, tramadol, oxazepam and diazepam. He systematically obtained prescriptio…

general practicepsychiatrysystemcommunicationcodeine
VIChome2016

Finding into death of Sharon Denise Siermans

29y · Female·blunt head injuries

Sharon Denise Siermans, a 29-year-old mother, was murdered by Jason Dinsley in April 2013 while he was on parole. Dinsley had a long history of violent sexual offences and had tested positive to cannabis in March 2013, t…

forensic medicinecorrectional healthsystemdelaycannabis
VICcommunity2016

Finding into death of XY

58y · Male·Combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propra…

A 58-year-old man with chronic depression, anxiety and personality disorders died from combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propranolol, diazepam) after presenting to ED with suicidal…

psychiatryemergency medicinediagnosticcommunicationeucalyptus oil
WAmental health2015-12-31

Inquest into the Death of Michael Ronald THOMAS

Unknown·Ruby: ligature compression of neck (hanging); Carly: ligature compression of nec…

Five young adults died by suicide within 12 months (March 2011 to March 2012), all connected to Alma Street Centre mental health services at Fremantle Hospital. Four were discharged (Ruby Nicholls-Diver, Carly Elliott, M…

psychiatryemergency medicinediagnosticcommunicationantidepressants
WAmental health2015-12-31

Inquest into the Death of Stephen Colin ROBSON

Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…

Five psychiatric patients of Alma Street Centre died between March 2011 and March 2012. Two (Ruby Nicholls-Diver and Anthony Edwards) died within 24 hours of discharge; two (Carly Elliott and Michael Thomas) died shortly…

psychiatryemergency medicinediagnosticcommunicationclozapine
WAmental health2015-12-31

Inquest into the Death of Ruby Natasha NICHOLLS-DIVER

Multiple - hanging (2), unknown/unascertainable (1), multiple injuries from fall…

Five patients of Alma Street Centre's psychiatric unit died within 12 months (2011-2012). Three died by suicide within 24 hours of discharge; one disappeared and died; one absconded while detained and died. Clinical less…

psychiatryemergency medicinecommunicationdiagnosticantidepressants
WAmental health2015-12-31

Inquest into the Death of Carly Jean ELLIOTT

Unknown·Ruby: ligature compression of the neck (hanging); Carly: ligature compression of…

Five young to middle-aged people with serious mental health conditions died by suicide within 12 months (March 2011 to March 2012) while under care from Alma Street Centre mental health services in Western Australia. Rub…

psychiatryemergency medicinecommunicationsystemantidepressants
WAmental health2015-12-31

Inquest into the Death of Anthony Ian EDWARDS

Female·Multiple causes: Ruby Natasha Nicholls-Diver: ligature compression of neck (hang…

Five psychiatric patients from Alma Street Centre (Fremantle Hospital) died by suicide within 12 months (March 2011-March 2012). Two died within 24 hours of discharge, demonstrating critical failures in mental health ser…

psychiatryemergency medicinediagnosticcommunicationantidepressants

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