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NSWcommunity2015-02-20

Inquest into the disappearance and suspected death of Margery Joyce TAYLOR

50y · Female·unascertained

Margery Joyce Taylor, aged 50, disappeared on 7 September 1978 from Warren, NSW. She had a long history of bipolar disorder and depression with prior psychiatric hospitalisations. Two months before disappearance, she was…

psychiatrygeneral practicesystemdelay
VIChospital2015-02-04

Finding into death of Joan Coutts

72y · Female·Pneumonia in the setting of multiple rib fractures and chronic obstructive pulmo…

A 72-year-old woman with COPD and diabetes presented to the emergency department on Good Friday with severe (9/10) right-sided chest pain from multiple rib fractures sustained in a fall. She was triaged to Category 5 (le…

emergency medicinegeneral practicediagnosticcommunication
VIChome2015-02-03

Finding into death of Alan Victor Webster

81y · Male·Intracerebral haemorrhage in the setting of heparinisation for subclavian artery…

81-year-old Alan Webster with atrial fibrillation on long-term Warfarin underwent colonoscopy in August 2011. His anticoagulation was interrupted and bridging Clexane prescribed. Post-operatively, critically sub-optimal …

cardiologyemergency medicinecommunicationsystemwarfarin
SAhome2015-01-30

Coroner's Finding: GIBSON Justin Lee

30y · Male·mixed butane, isobutane and propane toxicity

Justin Lee Gibson, a 30-year-old Indigenous man on home detention bail, died from inhalation of butane/propane causing fatal cardiac arrhythmia. He had a documented history of substance abuse (alcohol, cannabis, and buta…

emergency medicineforensic medicinecommunicationsystembutane
NSWcommunity2015-01-30

Inquest into the death of Alec Samuel MEIKLE

17y · Male·Hanging (self-inflicted)

Alec Meikle was a 17-year-old apprentice in New South Wales who experienced bullying and harassment at his workplace at Downer EDI from January to May 2008. The incidents included creation of a 'Sphincter Dilation Chart'…

psychiatrygeneral practicesystemfluoxetine
VICcommunity2015-01-20

Finding into death of Peter Oelfke

48y · Male·Haemophilus influenzae bronchopneumonia in the setting of alcohol and methadone …

Peter Oelfke, a 48-year-old man with alcohol and opioid dependence, died from haemophilus influenzae bronchopneumonia complicated by alcohol and methadone toxicity. He had no fixed address and lived in a tent. His GP pre…

general practiceforensic medicinemedicationsystemmethadone
TAScommunity2015

Coroner's Finding: Youth Suicide

suicide by hanging or other means

Six young people aged 12-17 years died by suicide between 2010-2014 in Tasmania. All had significant mental health issues, trauma histories, and contact with child protection services or schools. The coroner identified s…

psychiatrypaediatricssystemcommunicationlamotrigine
NSWcommunity2014-12-18

Inquest into the death of Kenneth MAWBY

59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of deliriu…

A 59-year-old man died by suicide on 5 January 2009, 47 days after undergoing Deep Brain Stimulation (DBS) surgery for Parkinson's disease. Post-operatively, he experienced significant behavioural changes including agita…

neurologyneurosurgerycommunicationsystemmadopar
VICcommunity2014-12-17

Finding into death of Paul Kanis

38y · Male·Organizing pneumonia with loculated pleural effusion in the setting of drug use …

Paul Kanis, a 38-year-old man with schizoaffective disorder, drug dependency, diabetes, and asthma, died from organizing pneumonia with loculated pleural effusion in the setting of methadone and benzodiazepine use. The c…

general practiceaddiction medicinecommunicationsystemmethadone
NSWcommunity2014-12-16

Inquest into the death of Massimo SUKLAN

59y · Male·opiate toxicity

Massimo Suklan, a 59-year-old man with schizo-affective disorder, chronic pain, liver disease and hepatitis, died from opiate toxicity while living in primitive conditions at a mining camp near Lightning Ridge. He had re…

psychiatrygeneral practicesystemmorphine
QLDcommunity2014-12-12

Hicks, Indianna Rose

5y · Female·Sudden Infant Death Syndrome (Classic Type 1a)

A 5-month-old infant died suddenly at a family day care facility on her first day of formal care, with autopsy findings consistent with Sudden Infant Death Syndrome (SIDS). The child had been fully swaddled with arms enc…

paediatricsforensic medicinesystemcommunication
VIChome2014-12-10

Finding into death of Phoebe Handsjuk

24y · Female·Exsanguination from injuries sustained while attempting to climb from a height i…

Phoebe Handsjuk, a 24-year-old woman with a history of depression, anxiety, and alcohol abuse, was found deceased in the refuse room of her apartment building on 2 December 2010. The coroner found she entered a garbage c…

psychiatrypsychologycommunicationsystemzolpidem
VIChospital2014-11-28

Finding into death of June Olive Pegg

80y · Female·peritonitis due to sigmoid resection margin leak following extended right hemico…

June Olive Pegg, 80, died from peritonitis following anastomotic leak after extended right hemicolectomy for colonic cancer. Critical delays in diagnosis occurred: a PET scan in May 2010 showed a colonic mass, but respir…

colorectal surgerygeneral surgerydiagnosticdelayfurosemide
QLDhome2014-11-26

Smith, Rachel Danielle - Non-inquest findings

25y · Female·mixed drug toxicity

Rachel Smith, a 25-year-old woman with chronic migraines and depression, died from mixed drug toxicity after consuming multiple prescription medications including oxycodone, codeine, tramadol, diazepam, amitriptyline and…

general practiceneurologydiagnosticsystemoxycodone
QLDhome2014-11-17

Beutel, Noelene Marie

36y · Female·traumatic head injuries from multiple assaults perpetrated by domestic violence …

Noelene Beutel died from severe head injuries inflicted by her domestic violence partner in 2011. Although she had engaged with police, GPs, hospitals, and domestic violence agencies in the six months before her death, s…

general practiceemergency medicinecommunicationsystem
VIChome2014-11-11

Finding into death of Tamara Ann Burt

32y · Female·Alcoholic ketoacidosis

Tamara Burt, 32, died of alcoholic ketoacidosis after isolating in her room and drinking excessively. She had bipolar affective disorder, alcohol dependence disorder, and borderline personality disorder traits. Despite o…

psychiatryaddiction medicinesystemcommunicationquetiapine
NTcommunity2014-11-03

Inquest into the death of Dion Daniels

24y · Male·Coronary artery thrombosis secondary to coronary atherosclerosis

A 24-year-old Aboriginal man collapsed during football in extreme heat and presented to a rural clinic with dizziness, chest pain, shortness of breath and sweating. The nurse diagnosed dehydration and administered IV flu…

cardiologyemergency medicinediagnosticcommunication
VIChome2014-10-30

Finding into death of Anne Christine Brain

44y · Female·Intoxication by the combined effects of tramadol, methadone, diazepam, codeine, …

Anne Christine Brain, a 44-year-old woman with schizophrenia, anxiety, and depression who was opioid-dependent, died from intoxication by combined effects of tramadol, methadone, diazepam, codeine, alprazolam, risperidon…

general practiceaddiction medicinesystemcommunicationtramadol
VIC2014-10-27

Finding into death of Kyle William Vassil

12y · Male·Unascertained in the setting of immersion; involuntary inhalation of water after…

Kyle Vassil, a 12-year-old competent swimmer, died by submersion in a cold, murky dam at a school camp. After 4-5 minutes of swimming, Kyle experienced acute difficulty, likely related to panic, anxiety, possible asthma,…

general practicecardiologysystemcommunication
VIChome2014-10-19

Finding into death of Hayley

2y · Female·head injury

Hayley, aged 2, died from severe head injuries sustained on 7-8 July 2009 at her home in St Arnaud, Victoria. She presented to childcare in the weeks before her death with unexplained bruising and injuries to her face an…

paediatricsforensic medicinediagnosticcommunication
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