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QLDhome2014-08-07

A four month old baby - Non-inquest findings

0y · Male·Sudden infant death syndrome (unclassified sudden infant death subclassification…

A four-month-old boy died in a caravan where he was placed in parental care following a Court Assessment Order. The cause was determined to be sudden infant death syndrome, possibly involving hypothermia given the cold e…

paediatricspathologysystemdelaymethamphetamine
QLDhospital2014-08-05

Olive, Thomas (Tom) Andrew

4y · Male·Severe rhabdomyolysis due to LPIN1 gene mutation

Tom Olive, aged 4, died from severe rhabdomyolysis caused by a rare LPIN1 gene mutation. Over 12 months before death, he presented with recurrent episodes of dark urine, muscle pain, and lethargy. Multiple GPs and a paed…

general practiceemergency medicinediagnosticcommunicationsuxamethonium chloride
QLDhome2014-07-28

Copeland, Alison Ruth - Non-inquest findings

55y · Female·Plastic bag suffocation

Alison Copeland, aged 55, died by plastic bag suffocation after living with severe physical disability and depression since suffering a subarachnoid haemorrhage in 1995. She had made multiple suicide attempts over 16 yea…

psychiatryneurologysystemdelaytemazepam
QLDhome2014-07-25

Petersen, Nicole - Non-inquest findings

19y · Female·Mixed drug toxicity, with morphine (from poppy seeds) and dextromethorphan (from…

Nicole Petersen, aged 19, died from mixed drug toxicity due to consumption of poppy seed tea combined with cough syrup and diazepam. She became unresponsive overnight and was discovered in cardiac arrest around 5:45am. H…

emergency medicinetoxicologydelaysystemmorphine
NT2014-07-21

Inquest into the death of Ryan Smiler

39y · Male·cardiac arrest caused by alcoholic cardiomyopathy

Ryan Smiler was a 39-year-old Aboriginal man who died from cardiac arrest caused by alcoholic cardiomyopathy while in custody at Darwin Correctional Centre. He had a long history of alcohol abuse, hypertension, and heart…

cardiologyemergency medicinedelaywarfarin
VIChome2014-07-18

Finding into death of Shyra Lee Bloomfield

16y · Female·hanging

A 16-year-old Aboriginal girl died by hanging after an episode of inhalant ('chrome') use and relationship breakdown. She had chronic substance abuse, complex psychosocial needs, learning difficulties, and disengagement …

paediatricsaddiction medicinesystemcommunicationinhalant
VICcommunity2014-07-14

Finding into death of Sarah Louise Booth

17y · Female·fatal motor vehicle collision during police pursuit

Sarah Booth, 17, died as a passenger in a vehicle fleeing police on 31 December 2006. This coroner's finding addresses systemic failures in Victoria Police's approach to pursuits rather than immediate clinical care issue…

correctional healthpublic healthsystemdelay
VIC2014-07-14

Finding into death of Jason Shaun Kumar

15y · Male·Injuries sustained in a motor vehicle collision

Jason Kumar, a 15-year-old in long-term state care, died in a motor vehicle collision whilst driving a stolen car at high speed through an intersection after a brief police pursuit was terminated. The vehicle was travell…

systemdelaycannabis
VIChospital2014-07-14

Finding into death of Mary Una Barnett

71y · Female·Diffuse Lymphoid Malignancy

Mary Una Barnett, a 71-year-old woman in custody at Dame Phyllis Frost Centre, died from diffuse lymphoid malignancy (high-grade lymphoma) discovered shortly before her death. She had extensive comorbidities including ch…

cardiologynephrologysystemdelay
NSWhospital2014-07-11

Inquest into the death of Toni Ann PEADON

52y · Female·laceration of the superior vena cava and right atrium during defibrillator lead …

A 52-year-old woman with a history of syncope and mitral valve prolapse, who had an implanted defibrillator, underwent a percutaneous laser lead extraction procedure at Westmead Hospital to remove and replace defective l…

cardiologycardiothoracic surgerysystemdelay
SAcommunity2014-07-07

Coroner's Finding: ABRAHIMZADEH Zahra

44y · Female·incised wound to the chest with superior pulmonary artery injury

Zahra Abrahimzadeh, aged 44, was stabbed to death by her estranged husband Ziaolleh in March 2010 at a Persian New Year event. Despite reporting repeated domestic violence to police in February 2009, Ziaolleh was never a…

diagnosticcommunication
VIChome2014-07-03

Finding into death of Daniel Michael Brendan Thomas

2y · Male·Unascertained causes; on balance of probabilities, inflicted injuries on evening…

Daniel Thomas, aged 2 years 8 months, died on 13 October 2003 from unascertained causes, likely inflicted injuries resulting from abuse. He had been living with Ms Martyn from September 2003, during which time he was sub…

paediatricsforensic medicinesystemdelay
VICcommunity2014-06-30

Finding into death of Lewis John Muratori

50y · Male·Multiple injuries as a result of being struck by a train

A 50-year-old ICU nurse at Cabrini Hospital died by suicide by stepping in front of a train after experiencing a cascade of adverse events. In October 2009, he attended work while intoxicated following personal stress, l…

psychiatryemergency medicinecommunicationsystemaurorix
QLDhome2014-06-27

Faith, an 8 year old child

8y · Female·Faith died from the combined effects of the haemodynamic consequences of extensi…

An 8-year-old girl, Faith, died from injuries caused by repeated beatings with a metal vacuum pole by her mother. She had previously disclosed abuse to school staff in 2009 and 2010, leading to Department investigations.…

paediatricsforensic medicinediagnosticsystem
NSWcommunity2014-06-27

Inquest into the deaths of Christopher SALIB, Nathan ATTARD and Shamsad AKHTAR

Christopher Salib: ischaemic heart disease with multiple prescription drug toxic…

This landmark inquest examined three deaths involving prescription drug toxicity: Christopher Salib (24, ischaemic heart disease with drug toxicity), Nathan Attard (34, multi-drug toxicity), and Shamsad Akhtar (35, multi…

general practiceemergency medicinediagnosticmedicationalprazolam
QLDhospital2014-06-20

O - Non-inquest findings

82y · Male·hypoxic-ischaemic encephalopathy due to cardiac arrest as a result of fractured …

An 82-year-old man died from hypoxic-ischaemic encephalopathy following perioperative cardiac arrest during ankle fracture surgery. The anesthetist failed to recognise clinical deterioration, did not intubate despite sig…

anaesthesiaorthopaedic surgerydiagnosticproceduralbisoprolol
VIC2014-06-19

Finding into death of Karl Harrison

69y · Male·Hypoxic ischaemic cerebral injury secondary to respiratory arrest in the setting…

Karl Harrison, a 69-year-old man with expertise in chemical products used for slate floor restoration, died from hypoxic ischaemic cerebral injury following respiratory arrest caused by exposure to dichloromethane fumes.…

forensic medicineemergency medicinesystemdelay
SAhome2014-06-17

Coroner's Finding: KOLBIG Drew Robin

37y · Male·stab wound to the chest penetrating the heart

A 37-year-old man with schizophrenia and a history of command auditory hallucinations died by self-inflicted stab wound to the chest. Released from psychiatric hospital on 11 April 2011 on voluntary arrangements without …

psychiatryoccupational therapydiagnosticcommunicationquetiapine
SAcommunity2014-06-17

Coroner's Finding: HUGO-HORSMAN Jason William

15y · Male·compression of the neck consistent with hanging

Jason Hugo-Horsman, a 15-year-old in Year 10, died by hanging while alone at home on 9 October 2010. He had been referred to Child and Adolescent Mental Health Services (CAMHS) in December 2009 and saw various therapists…

psychiatrypsychologydiagnosticcommunicationdiazepam
NSW2014-06-06

Inquest into the disappearance and suspected death of Jessica Beth SMALL

15y · Female·Abduction and murder by person or persons unknown

Jessica Small, 15, went missing in suspicious circumstances in October 1997 while hitchhiking in Bathurst, NSW. A witness (Vanessa Conlan) credibly reported abduction by an unknown man in a white Holden Commodore. The co…

systemcommunication

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