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VICaged care2016-02-08

Finding into death of Leslie Frederick Alexander

77y · Male·Subarachnoid and subdural haemorrhage post head trauma secondary to a fall

Leslie Alexander, 77, died from subarachnoid and subdural haemorrhage following a fall at an aged care facility. He fell on 29 March and again on 30 March 2015, striking his head. Initial assessment by a locum GP found n…

general practiceemergency medicinediagnosticcommunication
WAhospital2016-02-05

Inquest into the Death of Pauline Margaret DODD

51y · Female·Ischaemic heart disease

Pauline Margaret Dodd, 51, died of ischaemic heart disease at Sir Charles Gairdner Hospital on 4 March 2014. She was an involuntary psychiatric patient with long-standing bipolar affective disorder, complicated by childh…

psychiatrycardiologydiagnosticolanzapine
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
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

<1y · 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
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
VIChospital2016

Finding into death of Zakiya Crystal Lisa Thomas

15y · Female·Hanging

Zakiya, a 15-year-old Barkindji Maraura woman, died by hanging at Mildura Base Hospital following a family argument about repaying a borrowed $300. She had disclosed experiences of childhood sexual abuse by her uncle, ph…

psychiatrypaediatricscommunicationsystemcitalopram
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

Unknown·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
WAmental health2015-12-31

Inquest into the Deaths Alma Street Centre

Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…

Five former psychiatric patients of Alma Street Centre (part of Fremantle Hospital) died between March 2011 and March 2012. Two died by suicide within 24 hours of discharge; one disappeared and was found deceased; one ab…

psychiatryemergency medicinediagnosticcommunicationantidepressants
ACThospitalPodcast2015-12-18

AN INQUEST INTO THE DEATH OF CORRINA ANNE MEDWAY

32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin

A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…

obstetricsgeneral medicinediagnosticmedicationlabetalol
NSW2015-12-18

Inquest into the death of Officer A

43y · Female·External neck compression due to self-inflicted hanging

A 43-year-old NSW Police officer died by suicide on duty while suffering from work-related Major Depressive Disorder and PTSD. She had a suicide attempt in November 2012 that was not formally investigated as a new incide…

psychiatrypsychologydiagnosticsystemprescription medication
NSW2015-12-03

Inquest into the death of Adam Southwick

37y · Male·methyl amphetamine intoxication while being restrained in a confined space; posi…

Adam Southwick, a 37-year-old man severely intoxicated with methamphetamine, was placed in a cramped police charge dock while handcuffed and unable to walk. He died from methamphetamine intoxication complicated by positi…

emergency medicineforensic medicinediagnosticcommunicationmethamphetamine
VIChospital2015-12-02

Finding into death of Khodr El Mustapha

77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…

A 77-year-old man with iron deficiency anaemia and underlying ischaemic heart disease died from anaphylaxis following iron polymaltose infusion. Critical clinical lessons: (1) IV iron should only be administered after or…

emergency medicinehaematologydiagnosticproceduraliron polymaltose
NSWhospital2015-12-02

Inquest into the death of Jessica Martin

24y · Female·peri-myocarditis in the presence of sub clinical Addison's disease

Jessica Martin, 24 years old, died of peri-myocarditis in the presence of subclinical Addison's disease. She presented to the ED with chest pain on 30 June 2009 and was diagnosed with viral pleurisy without specific inve…

emergency medicineradiation oncologydiagnosticneurofen
TAShospital2015-11-27

Coroner's Finding: McManus, Pamela

75y · Female·large volume aspiration following right hemicolectomy for adenocarcinoma of the …

A 75-year-old woman with a 20-month history of iron deficiency anaemia was not investigated for its cause by her general practitioner despite clear clinical signs of deterioration. The coroner found this fell 'grossly sh…

general practicegeneral surgerydiagnosticcommunication
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