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NSWcommunity2017-07-12

Inquest into the suspected death of missing person Benjamin Stephens

23y · Male·Unable to be determined from available evidence

Benjamin Stephens, aged 23, went missing on 18 March 2004 from rural NSW and was confirmed deceased in 2016 when his skull was discovered via DNA matching. In the months before his disappearance, Ben developed symptoms c…

psychiatrygeneral practicesystemdelayquetiapine
VIChome2017-07-04

Finding into death of NJ

35y · Female·combined drug toxicity

A 35-year-old woman with long-standing substance use disorder, depression, and chronic pain died from combined drug toxicity involving methadone, pregabalin, methamphetamine, benzodiazepines, mirtazapine, promethazine an…

general practiceaddiction medicineprescribingcommunicationmethadone
SAhospital2017-06-22

Coroner's Finding: BAARTSE Leila Marijke

9y · Female·peritonitis due to perforated small bowel due to blunt abdominal trauma

Nine-year-old Leila Baartse-Harkin died from peritonitis due to a perforated small bowel sustained when she fell from a swing. Despite three medical encounters within 36 hours, the perforation was never diagnosed. At a r…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
VIChome2017-06-22

Finding into death of Steven Pimblett

47y · Male·Pneumonia

Steven Pimblett, 47, with mild intellectual disability, died of pneumonia at home. A home care worker noticed significant health deterioration over two months—inability to walk, laboured breathing, swollen feet—and suspe…

general practicepublic healthcommunicationsystem
QLDhome2017-06-20

KH - Non-inquest findings

35y · Female·Incised wound to neck

KH, a 35-year-old woman, was killed by her de-facto partner C through severe neck lacerations inflicted with a kitchen knife on 20-21 January 2011. C had an extensive history of violent offences and was subject to a prot…

emergency medicinegeneral practicesystemcommunicationalcohol
VIChome2017-06-20

Finding into death of Finding Ms RF

50y · Female·Potentially fatal multiple drug toxicity (oxycodone, mirtazapine, citalopram, cl…

Ms RF, a 50-year-old woman with epilepsy and chronic pain from a workplace wrist injury, died from potentially fatal multiple drug toxicity involving oxycodone, mirtazapine, citalopram, clonazepam, and pregabalin. She en…

general practiceneurosurgerysystemcommunicationoxycodone
TAShospital2017-06-16

Coroner's Finding: Baldock, Andrea Eileen

46y · Female·combined effects of aspiration pneumonia due to gastroparesis following sleeve g…

A 46-year-old woman died from aspiration pneumonia due to gastroparesis following sleeve gastrectomy, complicated by ischaemic heart disease. Post-operative recovery was beset with persistent vomiting, dehydration, and e…

general surgerygastroenterologysystemdelay
QLDaged care2017-06-09

DR - Non-inquest findings

46y · Female·Dilated cardiomyopathy (acute complication with sudden cardiac arrhythmia)

A 46-year-old woman with bipolar/schizoaffective disorder, poorly controlled type 2 diabetes, morbid obesity, severe obstructive sleep apnoea, and pulmonary hypertension died from acute dilated cardiomyopathy with sudden…

general medicineemergency medicinecommunicationsystemquetiapine
NSWcommunity2017-06-09

Inquest into the disappearance and suspected death of Katherine ACKLING-BRYEN

37y · Female·open finding - undetermined

Katherine Ackling-Bryen disappeared on 19 February 2016 and is presumed dead. She had a history of schizophreniform psychosis with a 2013 hospitalisation during which she expressed suicidal ideation. Post-discharge, she …

psychiatrygeneral practicesystemcommunicationanti-psychotic medication
VICaged care2017-05-31

Finding into death of Nerilee Elizabeth Barfoot

30y · Female·Global cerebral ischaemic injury and bronchopneumonia following PEA arrest in a …

A 30-year-old woman with Lennox-Gastaut Syndrome, a severe treatment-resistant epilepsy, died following cardiac arrest at a disability residential care facility. She was found entangled in a swing seat armrest on 7 April…

neurologyemergency medicinesystemcarbamazepine
SAcommunity2017-05-29

Coroner's Finding: WESTWOOD John Laurence

63y · Male·neck compression due to hanging

A 63-year-old man with treatment-resistant depression died by hanging. His wife had been maintaining a 'suicide watch' for six weeks prior to his death and telephoned his GP on the morning of his final appointment, expli…

general practicepsychiatrydiagnosticcommunicationmorphine
TAShospital2017-05-17

Coroner's Finding: Woulleman-Jarvis, Anne Maree 2017 TASCD 188

62y · Female·subacute subdural haematoma due to a closed head injury sustained in a fall from…

A 62-year-old woman on warfarin for a mechanical aortic valve sustained a head injury from a fall. A CT scan on day 5 post-injury identified a small extradural haematoma, but the radiologist (Dr J.) failed to report it, …

general practiceemergency medicinediagnosticcommunicationwarfarin
TAShospital2017-05-15

Coroner's Finding: Fellows, Peter Leslie

33y · Male·Decompensated congestive cardiac failure complicating acute myocardial infarctio…

A 33-year-old man with morbid obesity and steroid dependency presented with chest pain and light-headedness. Initial GP assessment missed acute coronary syndrome despite ECG changes on second visit. ED correctly diagnose…

cardiologyemergency medicinediagnosticmedicationbeta-blocker
WA2017-05-12

Inquest into the Death of Arulselvam VELMURUGU

35y · Male·bronchial asthma

A 35-year-old man with mild asthma died from severe bronchial asthma within hours of arriving at a Christmas Island immigration detention centre. He was initially identified as asthmatic at the jetty but not transferred …

emergency medicinegeneral practicecommunicationsystemsalbutamol
TAShospital2017-05-08

Coroner's Finding: McCall, Pamela

45y · Female·Mixed drug and alcohol toxicity, primarily due to propranolol

Pamela McCall, aged 45, died from mixed drug and alcohol toxicity on 12 February 2013. Her de facto partner, Dr B., a general practitioner, had been prescribing propranolol and panadeine forte for her since 2008 without …

general practiceemergency medicinecommunicationsystempropranolol
TASaged care2017-05-08

Coroner's Finding: Handasyde, Robert Neil

86y · Male·Sepsis with septic shock, due to urinary tract infection, pyelonephritis (kidney…

An 86-year-old man died from sepsis and septic shock secondary to urinary tract infection, pyelonephritis and prostatic infection. He presented to his GP in March 2015 with dizziness and reported urinary incontinence and…

general practicecardiologydiagnosticmedicationclopidogrel
NThome2017-05-05

Inquest into the death of Heather Fotiades

43y · Female·acute multiple drug toxicity on a background of chronic pain and morbid obesity

A 43-year-old woman died from acute multiple drug toxicity after 26 years of high-dose opioid therapy for chronic pain following a motor vehicle accident. Despite recognition by multiple clinicians that opioid doses exce…

general practicepain medicinediagnosticmedicationoxycodone
QLDaged care2017-05-03

Biffin, Albert Eric

86y · Male·Cardiac arrest triggered by electrolyte imbalance and sepsis secondary to compli…

An 86-year-old man with significant comorbidities died in a low-care nursing home from complications of an incarcerated umbilical hernia with bowel ischaemia, sepsis, and cardiac arrhythmia. His GP examined him briefly (…

general practicesurgerydiagnosticcommunicationmacrogol
VIChome2017-04-19

Finding into death of Lauren Pilkington

20y · Female·Asphyxia secondary to inhalation of helium

Lauren Pilkington, a 20-year-old postgraduate student, died by asphyxia from helium inhalation. She had a history of anxiety and previous suicide attempt, and was recently discharged from voluntary psychiatric admission …

psychiatrygeneral practicesystemdelayfluoxetine
SAhospital2017-04-07

Coroner's Finding: MAYELL Edward John

83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…

An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…

emergency medicinegeneral practicediagnosticmedicationceftriaxone
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