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QLDhome2014-09-26

H, a child

11y · Male·Asphyxia due to crush injuries from quad bike rollover

An 11-year-old boy with moderate intellectual disability died from asphyxia due to crush injuries when an adult-sized quad bike (460cc TGB) rolled onto him on a rural property driveway. He was riding unsupervised to a ne…

systemdelay
QLD2014-09-26

Moore, Geoffrey Grahame

51y · Male·Massive head injuries due to quad bike accident

Geoffrey Moore, a 51-year-old maintenance supervisor, died from massive head injuries after crashing a quad bike into a fence at a feedlot. The quad bike had a corroded and seized throttle cable that caused excessive rev…

systemdelaybuprenorphine
NSWhospital2014-09-26

Inquest into the death of AA

10y · Male·Hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…

A 10-year-old boy with severe obstructive sleep apnoea and morbid obesity died from hypoxic brain injury following cardiorespiratory arrest. Despite repeated medical interventions and explicit warnings that his condition…

respiratory medicineendocrinologycommunicationsystemmethadone
NSWhospital2014-09-26

Inquest into the death of AA

10y · Male·hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…

AA, a 10-year-old boy with morbid obesity and severe obstructive sleep apnoea, died from hypoxic brain injury after a cardiorespiratory arrest. He had been admitted to hospital in May 2008 with these diagnoses and was pr…

respiratory medicineendocrinologycommunicationsystemmethadone
NSWcommunityPodcast2014-09-16

Inquest into the death of Michael WILSON

42y · Male·Extensive blunt trauma injuries sustained during the course of rescuing an injur…

Michael Wilson, an experienced SCAT (Special Casualty Access Team) paramedic, died from extensive blunt trauma injuries sustained during a rescue operation at Bridal Veil Falls on 24 December 2011. A canyoner had fallen …

emergency medicineaviation medicineproceduralcommunication
VIChospital2014-09-12

Finding into death of Nola Margaret Moxon

77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression

77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission, no medical review occurred over the weekend prior to …

psychiatrygeriatric medicinecommunicationsystemvenlafaxine
VIChospital2014-09-09

Finding into death of Glenni Goodwin Ker

84y · Female·allergic reaction to metoclopramide (Maxalon) in a woman with acute myocardial i…

An 84-year-old woman with acute myocardial infarction (AMI) and ischaemic bowel died following an allergic reaction to intramuscular metoclopramide (Maxalon) administered by nursing staff without a doctor's order, despit…

general medicineemergency medicinemedicationproceduralmetoclopramide
QLDhospital2014-09-03

A Patient - Non-inquest findings

66y · Male·legionella pneumophila pneumonia

A 66-year-old man with multiple myeloma undergoing chemotherapy died from legionella pneumonia acquired from the Wesley Hospital water system. He was immunocompromised due to chemotherapy and corticosteroids, making him …

infectious diseasesoncologysystemcommunicationchemotherapy
NThome2014-09-01

Inquest into the death of Baby C

0y · Female·undetermined (chronic malnutrition ruled out; possible dehydration with electrol…

Baby C, born prematurely at 32 weeks (1.64kg), was discharged from Alice Springs Hospital on 2 January 2013 medically well and appropriately. She was placed in foster care with Ms Preston, an exceptionally experienced an…

paediatricsneonatologydelay
NTcommunity2014-09-01

Inquest into the death of Braydon Brown

17y · Male·bacterial meningitis

A 17-year-old Aboriginal student died from bacterial meningitis after three clinic presentations in Yuendumu over four days. The critical failure occurred on 1 April when fever (38.3°C), persistent headache, and positive…

general practiceemergency medicinediagnosticcommunicationdiazepam
VIChome2014-08-29

Finding into death of Deepak Kumar Prajapati

32y · Male·Smoke inhalation

Deepak Kumar Prajapati, a 32-year-old Indian national, died in a house fire on 3 January 2008 from smoke inhalation. The fire originated from an overloaded electrical power board connected to a computer monitor in a bedr…

systemdelay
VIChospital2014-08-29

Finding into death of Noella Rae Clohesy

62y · Female·Multi-organ failure due to lacerated abdominal aorta complicating laparoscopic b…

A 62-year-old woman died from multi-organ failure caused by a lacerated abdominal aorta sustained during elective laparoscopic gastric band surgery in 2006. The aorta was cut by a Visiport trocar blade at the start of th…

general surgeryanaesthesiaproceduralcommunication
VIC2014-08-28

Finding into death of Michael Atakelt

22y · Male·Consistent with drowning

Michael Atakelt, aged 22, died from drowning in the Maribyrnong River on 26 June 2011. He was last seen alive at 7:07pm at Newmarket railway station. His body was found 11 days later near Raleigh Road Bridge. The coroner…

systemcommunicationcannabis
QLDhome2014-08-26

McInnes, Zoe Louise

28y · Female·Multiple injuries due to quad bike accident

Ms Zoe McInnes, 28, died from multiple injuries sustained when she fell from a work-issued quad bike while returning home from a party at 2:30am. She was not wearing a helmet and struck her head on a dirt road. Contribut…

trauma surgeryneurosurgerysystemdelay
VICcommunity2014-08-25

Finding into death of Travis Joseph Hartskeerl

32y · Male·Head and neck trauma (train impact)

Travis Hartskeerl, a 32-year-old man with a complex history of schizophrenia, polysubstance abuse, and multiple serious suicide attempts, died by suicide on railway tracks on 16 December 2008. He had been discharged from…

psychiatrygeneral practicecommunicationsystemzuclopenthixol decanoate
VICcommunity2014-08-25

Finding into death of William Patrick Slater

67y · Male·Multiple injuries from motor vehicle collision

William Patrick Slater, aged 67, was killed in a motor vehicle collision caused by Kane Miller, a 24-year-old driver with schizophrenia who was on prescribed medication and had tested positive for morphine, cannabis, mid…

forensic medicinepsychiatrysystemdelaymorphine
NSWhospital2014-08-22

Inquest into the death of Alana GOLDSMITH

21y · Female·Multiple injuries sustained from being struck by a train; death by suicide while…

Alana Goldsmith, a 21-year-old woman with long-standing anorexia nervosa, died by suicide on 22 July 2011 after stepping in front of a train at Summer Hill Railway Station. She was admitted to Wesley Eating Disorder Clin…

psychiatrygeneral practicecommunicationsystemolanzapine
VICcommunity2014-08-13

Finding into death of Frederick Russell Morgan

48y · Male·Unknown causes (presumed suicide by drowning)

Frederick Russell Morgan, a 48-year-old stockbroker, disappeared on 15 July 1971 from Mt Martha beach. He had experienced severe depression triggered by business financial crises, tax assessment concerns, and his father'…

psychiatrypsychologydiagnosticdelayantidepressant medication
NSWhome2014-08-13

Inquest into the death of Sean Leigh MacWilliam

16y · Male·asphyxia due to hanging, self-inflicted, with aspiration of gastric contents as …

Sean MacWilliam, 16 years old, died by asphyxia due to hanging on 24 March 2011. He had been admitted involuntarily to an adult mental health facility (Chisholm Ross Centre) following a mental health crisis on 15 March 2…

psychiatryemergency medicinecommunicationsystemfluoxetine
QLDhome2014-08-11

Crane, Sylvia - Non-inquest findings

66y · Female·Pulmonary thromboembolism due to renal vein thrombus secondary to renal cell car…

Sylvia Crane, 66, died from pulmonary thromboembolism caused by tumour thrombus originating from renal cell carcinoma. She had a five-month delay in scheduling Category 1 surgery for nephrectomy due to systemic waitlist …

urologygeneral practicecommunicationsystem

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