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VIChome2023-05-25

Finding into death of Bradley Scott Liefvoort

46y · Male·Opioid toxicity (tapentadol and oxycodone)

Bradley Liefvoort, 46, died from opioid toxicity (tapentadol and oxycodone) at home in Dandenong. Over a decade of prescription medication misuse began with ibuprofen for headaches, escalating to opioid dependence follow…

general practicepain medicinemedicationsystemtapentadol
VIChome2023-05-25

Finding into death of Emma Gertrude Weidemann

76y · Female·Effects of fire in a woman with head and neck injuries

Mrs Emma Weidemann, aged 76, died from burns sustained in a fire deliberately set by her husband Rudolf at their home on 11 December 2019. Rudolf had recently been diagnosed with terminal cancer, experienced cognitive de…

oncologypsychiatrydiagnosticcommunicationvenlafaxine
NSWcommunity2023-05-25

Inquest into the disappearance and suspected death of Melissa CADDICK

49y · Female·Cannot be determined

Melissa Caddick, a financial advisor running a Ponzi scheme, disappeared on 12 November 2020 after ASIC executed a search warrant at her home. Her decomposed foot washed ashore 100 days later. Clinical lessons emerge: th…

psychiatryforensic medicinedelaysystem
VIChospital2023-05-24

Finding into death of Mr V

73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…

A 73-year-old man presented to ED with acute facial droop and speech difficulty on 5 September 2020. He was misdiagnosed with Bell's palsy despite clinical features suggestive of stroke. A non-contrast CT brain (inadequa…

emergency medicineneurologydiagnosticcommunicationprednisolone
VIChospital2023-05-23

Finding into death of Silin Wang

25y · Female·multiple injuries

A 25-year-old woman with newly diagnosed metastatic gastro-oesophageal cancer and depression died by suicide on hospital grounds. She was admitted on 30 January 2021 after imaging showed cancer progression. Her sister di…

oncologypsychiatrycommunicationsystemdiazepam
NSW2023-05-23

Inquest into the death of JS

34y · Male·Plastic bag asphyxia

A 34-year-old man on remand died by plastic bag asphyxia at Shortland Correctional Centre on 5 May 2020, hours before his release on bail. He had disclosed anxiety and depression, made multiple self-referrals for mental …

psychiatrypsychologydiagnosticcommunication
WAhospital2023-05-22

Inquest into the Death of Errol Warren BARTLETT

87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …

Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…

oncologypalliative carecommunicationsystemwarfarin
TAS2023-05-22

Coroner's Finding: Hyde-Wyatt, Michael Phillip

61y · Male·Pulmonary aspiration of gastric contents (post seizure) due to chronic communica…

Michael Phillip Hyde-Wyatt, aged 61, died from pulmonary aspiration of gastric contents following a seizure. He had chronic communicating hydrocephalus and encephalomalacia. At 1:30am, support worker Julie Magrath observ…

general practiceneurologycommunicationdelay
TAS2023-05-19

Coroner's Finding: Barwick, Ian John

67y · Male·Mechanical traumatic asphyxia from being run over by a tractor

Ian John Barwick, 67, died from traumatic mechanical asphyxia after being run over by a 50-year-old David Brown 780 tractor on his farm. While wintering cattle, Mr Barwick likely alighted from the tractor on a slope that…

system
TAScommunity2023-05-19

Coroner's Finding: Kirkwood, Jordan Thomas

19y · Male·hypoxic brain injury following asphyxia due to hanging

Jordan Kirkwood, a 19-year-old male, died by hanging on 30 April 2019 after being admitted to a newly established community-based mental health program (MHHITH) on 3 April 2019. He presented with depression, cannabis wit…

psychiatryemergency medicinediagnosticcommunicationfluoxetine
VIChospital2023-05-16

Finding into death of Mathew James Luttrell

43y · Male·Hanging

Mathew James Luttrell, a 43-year-old Aboriginal man with borderline personality disorder, chronic suicidal ideation and substance abuse, was admitted to Mildura Base Hospital following a suicide attempt on 11 November 20…

psychiatryemergency medicinecommunicationdelayolanzapine
VICaged care2023-05-15

Finding into death of Nickolaos Vlahos

92y · Male·Head and neck injuries sustained in a fall in a man with multiple co-morbidities

A 92-year-old man with dementia, multiple comorbidities, and a documented high falls risk died from head and neck injuries sustained in a fall at an aged care facility. He had experienced six falls over four months at th…

geriatric medicinesystemcommunication
SA2023-05-12

Coroner's Finding: Morrison, Wayne Fella

29y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to out of hospital …

Wayne Fella Morrison, a 29-year-old Aboriginal man with undiagnosed coronary artery disease (70% stenosis of right coronary artery), died following cardiac arrest during his detention at Yatala Labour Prison. After attac…

emergency medicineintensive caresystemdelay
TAShome2023-05-10

Coroner's Finding: PQ de-identified

51y · Male·self-inflicted chest injuries due to gunshot wound to chest

A 51-year-old man with a 37-year history of depression and alcoholism died by self-inflicted gunshot wound. He had ceased anti-depressant medication (desvenlafaxine) in September 2019 without documented clinical reason, …

general practicepsychiatrycommunicationsystemdesvenlafaxine
VIChome2023-05-10

Finding into death of P A

26y · Female·Pentobarbitone toxicity

PA, a 26-year-old veterinary nurse, died by suicide on 12 September 2021 using pentobarbitone accessed from her workplace. She had a history of depression and anxiety managed by her GP with antidepressants, but had becom…

general practicepsychiatrysystempentobarbitone
NSWhospital2023-05-09

Inquest into the death of Harriet Ostler

1y · Female·sudden cardiac death on a background of rhinovirus infection

Harriet Ostler, a 19-month-old toddler, was admitted to Port Macquarie Base Hospital with viral respiratory symptoms and died from sudden cardiac death due to underlying myocarditis/cardiomyopathy precipitated by rhinovi…

paediatricsemergency medicinediagnosticcommunicationsalbutamol
TAShospital2023-05-05

Coroner's Finding: Pedler, Anne Helen

71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis

71-year-old woman presented to ED with signs of circulatory failure (hypotension, tachycardia, tachypnoea, hypoxia) and progressive leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pulmonary emb…

emergency medicinecardiologydiagnosticdelaycannabis oil
NSW2023-05-05

Inquest into the death of John Cribb

67y · Male·Haemopericardium arising from a ruptured aorta (aortic dissection)

John Cribb, a 67-year-old man with known cardiac disease (coronary artery disease, aortic regurgitation, hypertension), died in custody from haemopericardium due to ruptured aortic dissection. He had signed a not-for-res…

cardiologypsychiatrysystem
TAShome2023-05-04

Coroner's Finding: Chuah Soo Lan

65y · Female·undetermined; possibly ischaemic heart disease or squamous cell carcinoma of ton…

A 65-year-old Malaysian woman with advanced squamous cell carcinoma of the tongue refused medical treatment due to visa concerns and preference for alternative therapy. She deteriorated over months with worsening oral sy…

oncologydentistrydelaysystem
VIChome2023-05-04

Finding into death of Jodie Overstead

34y · Female·Multi drug toxicity

Jodie Overstead, a 34-year-old with epilepsy, anxiety, and chronic pain, died from multi-drug toxicity involving tramadol, codeine, amitriptyline, benzodiazepines and other drugs. She engaged in 'doctor shopping', obtain…

general practicepain medicinediagnosticmedicationtramadol

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