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SAhospital2000-07-21

Coroner's Finding: DRESCHLER Michelle Lee

27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…

A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…

general surgerygeneral practiceproceduralcommunicationdiazepam
SA2000-07-07

Coroner's Finding: BAULDERSTONE Andrew Grant

37y · Male·Multiple injuries including lung lacerations and contusions, multiple rib fractu…

Andrew Grant Baulderstone, aged 37, died from multiple injuries when refractory material collapsed from the lining of a pellet kiln at BHP's Whyalla plant while he was jackhammering. The collapse resulted from failures i…

occupational and environmental healthforensic medicinesystemprocedural
WAcommunity2000-05-18

Inquest into the Death of Syoko Tsubaki

24y · Female·Immersion (drowning due to hypoxic brain injury)

Syoko Tsubaki, a 24-year-old Japanese tourist and inexperienced recreational diver, died from drowning on 31 December 1998 after a scuba diving incident at Rottnest Island on 27 December. During an afternoon dive, the di…

diving medicineemergency medicinecommunicationprocedural
SAhospital2000-04-12

Coroner's Finding: RUSSELL Brian Edward

80y · Male·bronchopneumonia complicated by morphine toxicity

An 80-year-old man with terminal liver disease died from bronchopneumonia complicated by morphine toxicity following a medication administration error. A Graseby infusion pump was incorrectly set at 99mm/hour instead of …

palliative caregastroenterologymedicationproceduralmorphine
VIC2000-02-03

HINTERHOLZ Frederich

61y · Male·Head injuries from forklift tipover

A 61-year-old licensed forklift driver died when a Crown 35 SC TT 240 forklift tipped while the mast was extended, crushing his head. He was not wearing a seatbelt. Although the coroner found the employer had exemplary s…

proceduralsystem
NThome1999-06

Inquest into the death of Clinton Leslie Kingsley

2y · Male·drowning

A 2-year-old Aboriginal boy drowned in an exposed septic tank at a remote community after plumbers removed concrete covers without installing replacements or notifying residents. The fibreglass lid's fastening screws had…

proceduralcommunication
VIChospital1999-03-29

JONES Eric

33y · Male·Postural asphyxia due to restraint (Posey Poncho vest)

A 33-year-old male admitted after drug overdose died from asphyxiation while restrained in a Posey Poncho vest. Successfully treated for overdose complications, he developed drug-induced delirium with agitation, promptin…

intensive careemergency medicineproceduralsystemmethadone
ACTcommunity1999

Inquest Into The Death Of Katie Bender

12y · Female·Head injury caused by high-velocity steel fragment missile, approximately 999 gr…

Katie Bender, aged 12, was struck fatally in the head by a 999-gram steel fragment while watching the controlled implosion of Royal Canberra Hospital on 13 July 1997. The fragment travelled 430 metres in 3.1 seconds at 1…

occupational and environmental healthdiagnosticprocedural
VIC1997-10-17

KEW Residential Services

Male·smoke inhalation and burns

On 8 April 1996, a fire at Kew Residential Services killed nine intellectually disabled residents (aged 31–61) from smoke inhalation and burns when a resident used a cigarette lighter to ignite bedding. The coronial inqu…

systemdelay
ACT1997

Inquest Into The Circumstances Surrounding The Death Of Shannon Robert Camden

21y · Male·Suffocation from hanging

Shannon Robert Camden, a 21-year-old with longstanding mental health difficulties and previous suicide attempts, died by hanging in cell A1 of the Belconnen Remand Centre on 15 April 1996 while on remand awaiting trial f…

psychiatrypsychologyproceduralsystem
VIC1996-09-02

GALLAGHER GREEN Kevin

39y · Male·neck injuries from being crushed between a hydraulic ram and hydraulically opera…

Kevin Gallagher-Green, 39, died from neck injuries when crushed between hydraulic machinery at BHP Western Port Steel Works while attempting to adjust a tilt table height. The coroner identified multiple system failures:…

proceduralsystem
VIChospital1996-08-16

LONG June

69y · Female·Asthma

June Sylvia Long, aged 69, suffered an asthma attack at home on 28 June 1994 and was transported to Alfred Hospital. She deteriorated overnight in the hospital's Respiratory Ward despite initial improvement in Emergency …

respiratory medicineemergency medicinediagnosticcommunicationsalbutamol
VICaged care

Finding into death of EMILIO VILLANUEVA

87y · Male·acute renal failure and two major haemorrhagic strokes

An 87-year-old man with multiple comorbidities including previous strokes, atrial fibrillation, and diabetes died from acute renal failure and two major haemorrhagic strokes after three months in an aged care facility. D…

geriatric medicinegeneral medicinecommunicationsystemmetformin
NT

Inquest into the death of Road Deaths 37, 38 and 39 of 2024

Unknown·Multiple blunt force injuries sustained in high-speed head-on motor vehicle coll…

Three people died in a head-on motor vehicle collision on the Stuart Highway near Hayes Creek, NT on 19 July 2024. A 71-year-old driver in a northbound vehicle crossed into the southbound lane while negotiating a curve, …

procedural
QLDcommunity

Peuckert, Bay Roxas - Non-inquest findings

48y · Female·Neck and chest injuries sustained in the incident with the cherry picker. Mechan…

Ms Peuckert, a 48-year-old farm worker with 12 years experience, died from crush injuries to her neck and chest while operating an Afron HAS-650 cherry picker on her employer's farm. She was directed to use the machine a…

systemcommunication
VICmental health

Finding into death of GM

52y · Male·Unascertained

GM, a 52-year-old man with bipolar affective disorder, died of unascertained causes after absconding from a mental health inpatient unit on 2 December 2015. He was admitted voluntarily for management of a suspected manic…

psychiatryemergency medicinesystemcommunicationpholcodine
NSW

Inquest into the death of Ali Antoni EL HAFIANE

19y · Male·Gunshot wound inflicted by NSW police officer during armed robbery

Ali Antoni El Hafiane, aged 19, was fatally shot by NSW Police during an armed robbery at the High Flyer Inn on 22 November 2010. The coroner found that while police acted courageously, the operation was poorly planned a…

systemcommunication

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