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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
QLDhome2015-06-19

Sweeney, Michael Shawn

42y · Male·Gunshot wound to the head

Michael Sweeney, aged 42, died from a self-inflicted gunshot wound to the head on 8 February 2013 while on parole. He attended his ex-partner's home in violation of a Domestic Violence Order to see their infant son. Afte…

psychiatrygeneral practicedelaymethamphetamine
WAhome2015-06-18

Inquest into the Death of MKP

15y · Female·Seizure Disorder in association with Long Standing Hypoxic Ischaemic Encephalopa…

MKP was a 15-year-old girl with severe cerebral palsy (GMFCS level 5) and long-standing hypoxic-ischaemic encephalopathy who died from a seizure disorder in her foster home on 26 December 2011. She had progressive respir…

neurologypaediatricsdelaydiazepam
ACTmental health2015-06-15

AN INQUEST INTO THE DEATH OF PETER ZOVAK

46y · Male·asphyxia by hanging

Peter Zovak, a 46-year-old with substance use history, presented to mental health services in November 2013 with first-episode psychosis. After initial hospital assessment and two CAT Team visits, his case was closed on …

psychiatryemergency medicinediagnosticcommunicationcannabis
VIChospital2015-06-12

Finding into death of Baby Chloe Lee Kellett

5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia

Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trac…

obstetricspaediatricsdiagnosticcommunicationoxytocin
QLDaged care2015-06-11

Ms C - Non-inquest findings

90y · Female·Infected sacral ulcer and fluid imbalances in the context of dementia

A 90-year-old woman with dementia, admitted to aged care in September 2012, developed a large necrotic sacral pressure ulcer despite nursing interventions. She was markedly dehydrated and malnourished, repeatedly refusin…

general practicegeriatric medicinecommunicationdelayfentanyl
QLDcommunity2015-06-09

JE and JJ, two 16 year old boys

16y · Male·Hanging (ligature compression of neck)

Two Indigenous young men, JE (16 years) and JJ (16 years), both died by hanging within four months during a suicide cluster in Mackay, Queensland in 2008. JE's death was impulsive, occurring after paint sniffing and alco…

psychiatryemergency medicinediagnosticcommunicationalcohol
NSWhome2015-06-09

Inquest into the death of Gabriele HANNEMANN

54y · Female·complications related to post-polio syndrome and chronic respiratory weakness; n…

Gabriele Hannemann, a 54-year-old woman with severe post-polio quadriplegia and chronic respiratory failure, died suddenly at home during consensual sexual activity. She had severely compromised lung function (13% predic…

respiratory medicinegeneral practicedelayparoxetine
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
WAhome2015-06-08

Inquest into the Death of Baby C

0y · Male·Group B Streptococcal infection and meconium aspiration with early bronchopneumo…

A newborn died of Group B Streptococcal (GBS) infection and meconium aspiration bronchopneumonia less than three hours after planned home birth. The infant was born to a woman with prior traumatic hospital birth who had …

midwiferyobstetricsdiagnosticdelay
WAhome2015-06-08

Inquest into the Death of Baby B

0y · Male·severe hypoxic ischaemic encephalopathy due to apparent perinatal asphyxia

Baby B suffered severe perinatal asphyxia during a planned home birth and died from hypoxic ischaemic encephalopathy. An obstetrician recommended hospital delivery based on the mother's previous unexplained neonatal emer…

obstetricsmidwiferycommunicationsystem
VIC2015-05-29

Finding into death of Ignac Lecek

68y · Male·Ischaemic small and large intestine complicating cardiogenic shock in the settin…

Ignac Lecek, 68, with hypertension and gout, collapsed in custody and died of ischaemic bowel complicated by cardiogenic shock in the setting of ischaemic heart disease. He complained of feeling ill on 2 October while in…

emergency medicinevascular surgerycommunicationsystemdiazepam
TAShome2015-05-27

Coroner's Finding: Pearce, Jasmine Rose

0y · Female·suffocation under bedding

Jasmine Rose Pearce, aged 11 months, died from suffocation under bedding in her family home on 27 January 2013. Her parents engaged in sexual activity on the bed where Jasmine was sleeping while under the influence of ca…

paediatricsemergency medicinesystemdelaycannabis
QLDhome2015-05-27

A, a six year old child

6y · Male·Hypoxic ischaemic encephalopathy due to drowning

A 6-year-old boy in foster care drowned in a backyard pool after removing his flotation device while his carer was distracted by a visitor. The carer, sitting on a veranda rather than in the pool enclosure as usual, was …

systemcommunication
QLDhospital2015-05-26

SM - Non-inquest findings

32y · Male·Pulmonary embolism originating from deep vein thrombosis in right calf

A 32-year-old man died from pulmonary embolism six days after emergency appendectomy for perforated appendicitis. VTE prophylaxis was appropriately prescribed. However, the clinical team failed to investigate persistent …

general surgeryanaesthesiadiagnosticcommunicationheparin
VICaged care2015-05-14

Finding into death of Philip John Roberts Hewitt

64y · Male·Acute traumatic subarachnoid haemorrhage secondary to single penetrating injury …

A 64-year-old man with schizophrenia was fatally stabbed in the eye by his roommate at a supported residential services facility. The roommate had a 12-year history of making specific threats to kill, including eye-pokin…

psychiatrygeneral practicediagnosticcommunicationolanzapine
VIChome2015-05-13

Finding into death of Dan Lin

21y · Female·Blunt force trauma to the head

Dan Lin, a 21-year-old woman, was killed by her mother-in-law in a violent domestic assault. This death occurred within the context of family violence, with prior documented physical assaults by the perpetrator in July 2…

forensic medicinegeneral practicecommunicationsystem
NSW2015-05-12

Inquest into the death of John Vincent CREAN

25y · Male·Suspicious death, likely homicide; exact cause undetermined

John Vincent Crean disappeared on 6 January 1980 aged 25, found dead on balance of probabilities. While no body was recovered, all evidence indicates suspicious death, likely homicide related to drug debts owed to George…

systemdelay
VICmental health2015-05-07

Finding into death of Narelle Ena Clancy

49y · Female·Hanging

Narelle Clancy, aged 49, absconded from a psychiatric ward within hours of being placed on involuntary status and died by hanging. She had a long history of depression and suicidal ideation following her daughter's suici…

psychiatrycommunicationsystemolanzapine
VICcommunity2015-05-07

Finding into death of Krisinda Carmen Smart

15y · Female·toxicity to heroin

Krisinda Carmen Smart, aged 15, died from heroin toxicity on 20 January 2008. She was a child in care of the Department of Human Services subject to a Custody to Secretary Order. In the days before her death, there were …

paediatricsemergency medicinediagnosticsystemheroin

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