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VIC2019-10-18

Finding into death of Mr A

24y · Male·Mixed drug toxicity

A 24-year-old man died from mixed drug toxicity after staying overnight at a backpackers hostel. He had a history of anxiety and shoulder pain following 2015 surgery, for which he received multiple medications including …

psychiatrygeneral practicecommunicationsystempregabalin
VIC2019-10-16

Finding into death of FDS

34y · Male·Mixed drug toxicity

FDS, a 34-year-old male recently released from prison, died from mixed drug toxicity after injecting heroin in a public toilet. He had a long-standing complex drug history and relapsed shortly after release despite parol…

general practiceforensic medicinecommunicationdelayheroin
VICaged care2019-10-14

Finding into death of Grant White

65y · Male·Cardiomegaly

Grant White, a 65-year-old man with cardiomegaly and severe mitral regurgitation living in Department of Health and Human Services disability accommodation, died from cardiomegaly on 11 September 2017. Two days before hi…

cardiologygeneral practicesystemcommunicationhaloperidol
VIChome2019-10-10

Finding into death of Liana Pickup

32y · Female·Mixed drug toxicity (methadone, oxycodone, desmethylvenlafaxine, quetiapine, ola…

Liana Pickup, a 32-year-old woman with complex mental illness (bipolar disorder, borderline personality disorder, schizoaffective disorder), chronic back pain, and substance dependence, died from mixed drug toxicity afte…

general practicepsychiatrymedicationcommunicationmethadone
VIChome2019-10-07

Finding into death of Phillip James King

52y · Male·Mixed drug toxicity

A 52-year-old man with multiple sclerosis, chronic pain, depression and history of suicidality died from mixed drug toxicity following an intentional overdose. He was prescribed multiple opioids (fentanyl, tramadol, oxyc…

general practiceneurologymedicationcommunicationfentanyl
NT2019-09-27

Inquest into the death of Daryl Riley

42y · Male·ischaemic heart disease due to coronary artery atherosclerosis and left ventricu…

Daryl Jabangardi Riley, a 42-year-old Aboriginal prisoner, died of ischaemic heart disease due to coronary artery atherosclerosis and left ventricular hypertrophy while playing pool in the recreation room at Alice Spring…

cardiologygeneral practicediagnosticcommunication
NSWaged care2019-09-27

Inquest into the death of Epenesa PAHIVA

87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…

Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (h…

dermatologygeneral practicediagnosticcommunicationbleach
NSWaged care2019-09-27

Inquest into the death of Sylvia CONFOS

87y · Female·Natural causes in the context of multiple co-morbidities including a sacral ulce…

87-year-old woman died in aged care with a stage 4 sacral ulcer and multiple comorbidities. Key clinical lessons: (1) Systematic communication failures—family was not informed that a healed sacral wound re-emerged in Mar…

geriatric medicinegeneral practicecommunicationsystemrozex
VIChospital2019-09-23

Finding into death of Leslie Roberts

76y · Male·Hypothermia and multiorgan failure complicating compound left tibia and fibula f…

Leslie Roberts, a 76-year-old man with intellectual disability under DHHS care, died from hypothermia and multiorgan failure following a compound fracture of the left tibia and fibula sustained in a fall at home. He was …

emergency medicineorthopaedic surgerysystemdelay
NThospital2019-09-20

Inquest into the death of Joanne Craig

57y · Female·multi-organ failure due to sepsis caused by streptococcus pneumoniae infection

Joanne Craig, a 57-year-old Aboriginal woman, presented to Katherine District Hospital on 24 January 2018 with fever, vomiting, and cough. She had streptococcus pneumoniae sepsis with elevated inflammatory markers from 1…

emergency medicinegeneral practicediagnosticcommunicationondansetron
QLDcommunity2019-08-02

Ms D - Non-inquest findings

47y · Female·Overdose of hydromorphone

A 47-year-old woman died from an intentional overdose of prescribed hydromorphone while residing at a domestic violence refuge. She had a history of depression, previous suicide attempts, and was in crisis following sepa…

psychiatrygeneral practicediagnosticcommunicationhydromorphone
VIChospital2019-08-01

Finding into death of Tyla Jade Hovenbitzer

18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…

An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…

paediatricsgeneral practicesystemdelaytemazepam
ACThome2019-07-31

Inquest into the death of Cheyse Williams-Empson

3y · Male·unascertained

A 3-month-old boy died with an unascertained cause after being found unresponsive in his bassinet with a blanket covering his mouth and face. His mother had ongoing heroin use throughout pregnancy and postnatally, concea…

neonatologyforensic medicinecommunicationsystemheroin
VICaged care2019-07-31

Finding into death of Hong Tay

63y · Male·Sepsis in a man with complicated peripheral vascular disease

Hong Tay, a 63-year-old man with extensive peripheral vascular disease, diabetes, and prior amputations, died from sepsis in an aged care facility following a cervical spine fracture sustained in a fall. After conservati…

geriatric medicinepalliative carecommunicationsystemfentanyl
VIChospital2019-07-30

Finding into death of Allison Judith Allan

43y · Female·Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxic…

43-year-old woman with epilepsy and depression died from hypoxic ischaemic brain injury after ingesting 15g sodium valproate and 750ml vodka. Critical failures occurred across multiple settings: VPIC provided incomplete …

emergency medicineintensive carediagnosticcommunicationsodium valproate
NSWhospital2019-07-29

Inquest into the death of Naomi Williams

27y · Female·Septicaemia secondary to Neisseria meningitides infection

Naomi Williams, a 27-year-old Wiradjuri woman, died from meningococcal septicaemia on 1 January 2016. She presented to Tumut Hospital in the early hours with generalised aches and pains while pregnant. Despite vital sign…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
VIChome2019-07-18

Finding into death of Christopher George

28y · Male·Gunshot wound to the head

Christopher George, a 28-year-old man with a history of depression and suicidal ideation, died from a self-inflicted gunshot wound while police conducted a welfare check at his home. He had stopped taking sertraline (ant…

psychiatrygeneral practicesystemsertraline
QLDhome2019-07-15

Male child aged 20 months - Non-inquest findings

20y · Male·Lung infection on a background of oxycodone intoxication

A 20-month-old Aboriginal boy died from lung infection on a background of oxycodone intoxication after ingesting oxycodone tablets located in his grandparents' home. The child's grandparents had obtained 560 oxycodone ta…

general practiceforensic medicinediagnosticmedicationoxycodone
NSW2019-07-05

Inquest into the death of Rebecca Maher

36y · Female·respiratory depression after loss of consciousness caused by mixed drug toxicity…

Rebecca Maher, a 36-year-old Aboriginal woman, died from respiratory depression caused by mixed drug toxicity (high levels of Alprazolam and Methadone) while detained as an intoxicated person at Maitland police station. …

general practicepharmacydiagnosticmedicationalprazolam
ACThospital2019-06-25

Inquest into the death of Jay Alan Paterson

43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …

Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone table…

general practicepain medicinesystemproceduraloxycodone
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