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VICmental health2023-06-22

Finding into death of Catherine Ann Williamson

58y · Female·plastic bag asphyxia

Catherine Williamson, a 58-year-old voluntary psychiatric inpatient, died from plastic bag asphyxia at a private mental health facility. She had schizo-affective disorder and a history of suicide attempts. Despite return…

psychiatrysystemcommunication
VIC2023-06-22

Finding into death of Cherie Virginia Pearl Guest

61y · Female·Diffuse alveolar damage in a woman with restrictive lung disease following catar…

A 61-year-old woman with severe restrictive lung disease, obesity, cardiac failure, and diabetes underwent cataract surgery at a private day surgery centre on 13 August 2018. She was unable to lie flat and became hypoxic…

ophthalmologyanaesthesiadiagnosticcommunicationlidocaine
VICmental health2023-06-22

Finding into death of Veronika (Veronica) Anastasia Kouros

31y · Female·Plastic bag asphyxia

31-year-old Veronika Kouros, a voluntary inpatient at Northern Psychiatry Unit with bipolar affective disorder, obsessive-compulsive disorder, and depression, died by plastic bag asphyxia on 19 March 2018. Despite hospit…

psychiatrygeneral practicesystemproceduralquetiapine
NSWcommunity2023-06-16

Inquest into the death of Brandon Clark

23y · Male·In keeping with drowning

Brandon Clark, a 23-year-old Aboriginal man, died by drowning in the Manning River during a police foot pursuit on 22 January 2022. He was stopped while in a vehicle following drug intelligence, gave false identity detai…

emergency medicinetoxicologysystemdelaymethamphetamine
TAShospital2023-06-13

Coroner's Finding: HN de-identified

83y·cardiac tamponade due to haemopericardium resulting from traumatic parietal peri…

An 83-year-old woman presented to the ED with chest pain and was found to have a pericardial effusion. She underwent an aortic angiogram but critical investigations including echocardiography were not clearly documented.…

emergency medicinecardiologyproceduralsystem
VIChome2023-06-08

Finding into death of Mayumi Spencer

29y · Female·Cocaine toxicity

Mayumi Spencer, a 29-year-old woman, died from cocaine toxicity on 17 January 2015. At approximately 4:00 AM, her husband Dr S. discovered her having a seizure and vomiting. Rather than immediately calling emergency serv…

emergency medicinetoxicologydelaysystemcocaine
VIChome2023-06-06

Finding into death of Michael Stephen Delaney

37y · Male·Plastic bag asphyxia

Michael Delaney, a 37-year-old man with treatment-resistant schizophrenia, died by plastic bag asphyxia while residing at supported independent living accommodation. He had multiple suicide attempts and was under the car…

psychiatrycommunicationsystemdiazepam
NSW2023-06-06

Inquest into the death of CJ

56y · Male·hanging (neck compression)

CJ, a 56-year-old man, died by hanging in custody at Bathurst Correctional Centre on 31 December 2020, shortly after the suicide of his son in June 2020. He had recently been remanded in custody on domestic violence char…

psychiatrygeneral practicecommunicationsystem
NTPodcast2023-06-05

Inquest into the death of Nigel Harris

60y · Male·multiple blunt force injuries

Nigel Harris, age 60, died when struck by Trophy Truck #499 at the 35 km sand dune during the 2021 Finke Desert Race in Alice Springs, NT. The driver experienced mechanical failure (rear axle trailing arm fracture) causi…

systemdelay
VICcommunity2023-06-05

Finding into death of Peter Boyle

61y · Male·Drowning

Peter Boyle, 61, drowned in McMillan Strait after jumping into water to free a sail line entangled in his yacht's propeller. He had Parkinson's disease affecting balance and swimming ability, wore only underwear without …

occupational and environmental healthneurologysystemamantadine
VICcommunity2023-06-05

Finding into death of Brad Anthony Godressi

40y · Male·Cardiomyopathy in the setting of immersion and amphetamine use

Brad Godressi, a 40-year-old man with end-stage dilated cardiomyopathy recently discharged against medical advice from ICU, died from cardiomyopathy in the setting of immersion and amphetamine use while operating a boat …

cardiologyintensive caresystemdelayamphetamine
TAShospital2023-05-31

Coroner's Finding: Richardson Rebecca Eileen

29y · Female·acute myocardial infarction due to stenotic coronary vessel (left anterior desce…

Rebecca Richardson, a 29-year-old with type 1 diabetes and coronary artery disease, died of acute myocardial infarction on 7-9 May 2019. She presented to NWRH ED on 6 May with abdominal pain and vomiting, initially attri…

emergency medicinecardiologydiagnosticcommunicationinsulin
VIChospital2023-05-29

Finding into death of Kaleb Baylis-Clarke

0y · Male·Head injury in the setting of chronic subdural haemorrhage

Kaleb Baylis-Clarke, a 17-week-old infant, presented to hospital on 14 January 2016 with a head lump, vomiting, raised fontanelle and reduced milk intake. Cranial ultrasound showed fluid in subdural spaces. MRI on 15 Jan…

paediatricsneurosurgerysystem
VIChome2023-05-29

Finding into death of Stuart John Noble

47y · Male·Multidrug toxicity (ethanol, quetiapine, baclofen, benzodiazepines)

Stuart Noble, 47, died from multidrug toxicity involving baclofen, quetiapine, benzodiazepines, and ethanol in an intentional overdose. He was prescribed baclofen off-label by his GP for alcohol use disorder despite it l…

general practiceaddiction medicinediagnosticsystembaclofen
WAhospital2023-05-26

Inquest into the Death of Jacob George Isaac TAULELEI

28y · Male·Multiple injuries sustained when struck by a freight train

Jacob Taulelei, a 28-year-old man with long-standing depression, anxiety, and suicidal ideation, presented to St John of God Hospital on 5 February 2020 expressing intent to jump in front of a train. Despite being assess…

psychiatryemergency medicinediagnosticcommunicationduloxetine
SAcommunity2023-05-26

Coroner's Finding: Latouche Mazzei, Lucas

5y · Male·acute upper airway obstruction from nectarine stone

Lucas Mazzei, aged 5 years, died on 27 March 2017 from acute upper airway obstruction caused by an uncut nectarine stone. While attending school, he was separated from his class during a science lesson and left watching …

emergency medicinepaediatricscommunicationsystemlamotrigine
NSW2023-05-26

Inquest into the deaths of Emma Bowden, Heather Bowden-Page, Edward Cousins, Richard Cousins, William Cousins & Gareth

Unknown·Multiple blunt force injuries and immersion secondary to seaplane crash caused b…

On 31 December 2017, a de Havilland DHC-2 Beaver seaplane crashed into Jerusalem Bay, Sydney, killing all six occupants. The coroner found the crash was caused by pilot impairment due to carbon monoxide (CO) exposure. Pr…

forensic medicinepathologyproceduralsystemcarbon monoxide
NSWcommunity2023-05-26

Inquest into the death of Benjamin Woodhouse

59y · Male·Drowning

Benjamin Woodhouse, a 59-year-old involuntary mental health patient with schizophrenia and a history of absconding, drowned in the Parramatta River while on escorted leave. Critical systemic failures included inadequate …

psychiatrycommunicationsystem
NSW2023-05-26

Inquest into the death of Azhar Abdul

26y · Male·hanging

Azhar Abdul, aged 26, died by hanging in Bathurst Correctional Complex while in protective custody. He had requested removal from the Honour House program on 27 February 2022, citing external threats and a debt to motorc…

forensic medicinecorrectional healthcommunicationsystem
TAShome2023-05-25

Coroner's Finding: CE de-identified

69y · Male·amitriptyline and alcohol toxicity with ischaemic heart disease

A 69-year-old man with longstanding anxiety, depression, heavy alcohol use, and multiple prior intentional overdoses of amitriptyline died from combined amitriptyline and alcohol toxicity with underlying ischaemic heart …

psychiatrygeneral practicesystemcommunicationamitriptyline

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