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TAShome2018-07-13

Coroner's Finding: Mackozdi, Janet Lois

77y · Female·hypothermia from environmental cold exposure with contributing factors of advanc…

Mrs Janet Mackozdi, aged 77, died from hypothermia in an uninsulated shipping container at Mount Lloyd, Tasmania, on 23-24 July 2010. She had advanced Alzheimer's dementia and required 24-hour care. The coroner found her…

geriatric medicinegeneral practicesystemcommunication
NSW2018-07-13

Inquest into the death of Sony William Tran-Bui

33y · Male·complications of acute peritonitis caused by rupture of a duodenal ulcer

Sony William Tran-Bui, aged 33, died from acute peritonitis caused by a ruptured duodenal ulcer while in custody at Silverwater Correctional Centre in November 2013. The death was not preventable given the sudden, unexpe…

gastroenterologyemergency medicinecommunicationsystemdiazepam
VIChome2018-06-28

Finding into death of Raymond John Cox

84y · Male·Gunshot wound to the head

Raymond John Cox, an 84-year-old man with Alzheimer's disease, depression, and cognitive decline, died from a self-inflicted gunshot wound to the head. His wife had approached police in 2013 seeking assistance to remove …

general practicegeriatric medicinecommunicationsystemcitalopram
QLD2018-06-28

Hamilton, Blair Andrew

54y · Male·Extensive burns due to detonation of LPG gas cylinder

A 54-year-old man with chronic severe depression, grief from his wife's sudden death, severe debilitating skin condition, and alcohol dependence called emergency services on 12 December 2015, warning them not to approach…

psychiatrygeneral practiceproceduralcommunicationvenlafaxine
NSW2018-06-26

Inquest into the death of Glen Russell

32y · Male·asphyxia arising from neck compression from self-inflicted ligature strangulatio…

Glen Russell, 32, died by suicide in Cessnock Correctional Centre while on remand. He had a complex history including childhood sexual assault, schizophrenia diagnosis, heroin use, and recent self-harm episodes. Although…

psychiatrygeneral practicediagnosticcommunicationmirtazapine
ACThome2018-06-25

INQUEST INTO THE DEATH OF SUELLEN EDITH DAVIS

57y · Female·Positional asphyxia caused by the combined effect of consumption of several opia…

57-year-old woman with chronic pain died from positional asphyxia caused by consumption of multiple sedative medications. She was prescribed opioids (Fentanyl, Oxycodone) and Pregabalin, but also obtained Dolased and Pro…

general practicepain medicinecommunicationsystemoxycodone
QLD2018-06-20

Holstein, Zachary James David

23y · Male·Hypoxic-ischaemic encephalopathy due to hanging

Zachary James David Holstein, age 23, died by suicide by hanging in Woodford Correctional Centre on 8 February 2016 (declared extinct 12 February 2016). He had a history of substance abuse, self-harm, and mental health d…

psychiatrycorrectional healthdelaysystemmirtazapine
QLDcommunity2018-06-05

Smit, Bernardus Johan

50y · Male·Head injuries due to motor vehicle accident

A 50-year-old traffic controller was struck and killed by a motor vehicle driven by a woman with multiple serious medical conditions (end-stage renal disease, multiple myeloma) who was taking Panadeine Forte. The driver …

general practicehaematologysystemparacetamol/codeine
QLDaged care2018-06-05

Milward, Paul Joseph

53y · Male·Choking on food bolus in pharynx, with Huntington's disease and coronary atheros…

Paul Joseph Milward, aged 53 with Huntington's disease causing cognitive impairment and swallowing difficulties, died from choking on a bread sandwich while unsupervised in his aged care room. His care plan specified min…

geriatric medicinespeech pathologycommunicationsystemsodium valproate
NSWhospital2018-05-30

Inquest into the death of Marcia Clark

83y · Female·Combined effects of severe malnutrition and infection (septicaemia secondary to …

Mrs Clark, 83, died from severe malnutrition and infection including septicaemia from an infected sacral pressure ulcer that had existed for 7 months. She was admitted to hospital in a deplorable state with severe pressu…

geriatric medicinegeneral practicediagnosticcommunicationolanzapine
NSWhome2018-05-25

Inquest into the death of J

0y · Female·Unascertained

A four-month-old girl died in an unsafe sleeping environment while staying with relatives in Sydney. She was placed in a pram in her parents' bedroom and was found not breathing on the morning of 17 August 2014. The exac…

paediatricsgeneral practicesystemdelay
SAhospital2018-05-23

Coroner's Finding: LA BELLA Claudia

28y · Female·aspiration of gastric contents complicating laxative abuse

A 28-year-old woman died from aspiration of gastric contents complicating severe laxative abuse. She fabricated a terminal cancer diagnosis to conceal anorexia nervosa and factitious disorder. During a RAH admission, a C…

general practicegeneral medicinediagnosticcommunicationbisacodyl
QLDhome2018-05-21

House, William John; White, Vanessa Joan; Smith, Jodie Anne and Milne, Daniel Keith

Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…

Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…

general practicepain medicinediagnosticmedicationfentanyl
QLDhospital2018-05-04

LM - Non-inquest findings

1y · Female·Sepsis (Group A Streptococcus)

A nearly 16-month-old girl died from Group A Streptococcal sepsis after presenting to a regional private hospital emergency department. She had been seen multiple times by different GPs in the preceding weeks with viral …

general practiceemergency medicinediagnosticdelaymupirocin
NSWhospital2018-05-03

Inquest into the death of Naomi Watson Ley

33y · Female·hanging, self-inflicted with intention of taking her own life

Naomi Watson Ley, a 33-year-old woman with a history of depression and borderline personality disorder, was admitted to Royal North Shore Hospital following suicidal ideation after medication changes (moclobemide to cita…

psychiatryemergency medicinediagnosticcommunicationmoclobemide
NSWhome2018-04-26

Inquest into the death of FW

79y · Male·external neck compression as a result of hanging

A 79-year-old man with bipolar affective disorder and a documented history of medication non-compliance died by suicide while living in rural NSW. He had been subject to a Victorian Community Treatment Order (CTO) requir…

psychiatrygeneral practicecommunicationsystemrisperidone
NSW2018-04-20

Inquest into the death of Stephen Hodge

51y · Male·combined effect of gunshot injuries to the chest and abdomen

Stephen Hodge, a 51-year-old postal worker with a history of depression, anxiety, and alcohol use disorder, was shot by police after advancing on them with a large kitchen knife. He had consumed substantial alcohol and p…

emergency medicinepsychiatrycommunicationsystemalcohol
ACT2018-04-11

AN INQUEST INTO THE DEATH OF STEVEN CLAUDE FREEMAN

25y · Male·Aspiration pneumonia secondary to methadone toxicity

Steven Claude Freeman, a 25-year-old Aboriginal man, died of aspiration pneumonia secondary to methadone toxicity on 27 May 2016, while incarcerated at the Alexander Maconochie Centre in the ACT. He was assessed as opioi…

addiction medicinegeneral practicediagnosticsystemmethadone
VICcommunity2018-04-09

Finding into death of Benjamin Gleeson

37y · Male·Carbon monoxide poisoning

Benjamin Gleeson, a 37-year-old man, died from carbon monoxide poisoning by exhaust inhalation. He had a history of methamphetamine use, depression with suicidal ideation, and was a perpetrator of family violence. Despit…

psychiatrygeneral practicesystemmethamphetamine
VICcommunity2018-03-30

Finding into death of Antonia Victoria Lourandos

22y · Female·Complications of megacolon due to chronic constipation in a woman with cerebral …

A 22-year-old woman with severe cerebral palsy and epilepsy died of complications from megacolon due to chronic constipation. She attended respite care over a weekend and became unwell with feeding difficulties and abdom…

disability medicinegastroenterologysystemcommunicationdiazepam
131323359

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