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SAhospital2014-02-05

Coroner's Finding: COOK Eileen Hazel

76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…

Mrs Cook, a 76-year-old woman, died in January 2010 from hospital-acquired pneumonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangerously…

general practiceemergency medicinediagnosticcommunicationintravenous fluids
VIChospital2014-02-05

Finding into death of Margareta Snopek

67y · Female·Lithium toxicity with chest infection and bipolar disorder; Alzheimer's disease …

Mrs Snopek, aged 67 with bipolar disorder on long-term lithium, was prescribed coversyl (an ACE inhibitor) by Dr A. in January 2008 for hypertension. This combination is contraindicated as ACE inhibitors impair renal fun…

general practiceneurologymedicationdiagnosticlithium carbonate
VICaged care2014-01-30

Finding into death of Bernadette Angelina Rogers

65y · Female·Aspiration pneumonia with Down syndrome as underlying condition

Bernadette Rogers, a 65-year-old woman with Down syndrome and intellectual disability, died from aspiration pneumonia with severe oropharyngeal dysphagia as a contributing factor. She had suffered recurrent chest infecti…

general practicepalliative caresystemsalbutamol
QLDprison2014-01-24

Lingwood, Craig Steven

45y · Male·metastatic malignant melanoma

Craig Lingwood, a 45-year-old prisoner, died from metastatic melanoma in May 2011. He first complained of a suspicious mole (red, itchy, bleeding) in 2005-2006, but the prison doctor (Dr C.) assessed it as benign in Augu…

dermatologygeneral practicediagnosticsystem
WAprison- 31 January 2014

Inquest into the Death of Amy TINKER

33y · Female·multiple organ failure complicating sepsis in a woman with cirrhosis of the live…

Amy Tinker, a 33-year-old Aboriginal woman with unrecognised cirrhosis from chronic alcohol abuse, died from sepsis-related multi-organ failure while imprisoned. She had been admitted to Royal Perth Hospital in 2004 with…

general practicehepatologycommunicationsystem
WAhome- 15 May 2014

Inquest into the Death of Helen Barbara MINETT

55y · Female·Multiple drug toxicity in a woman with coronary artery atherosclerosis

A 55-year-old woman with complex medical history including chronic pain, previous multiple abdominal surgeries, gastrointestinal disorders, mental health issues including DID, and suicidal ideation died from multiple dru…

general practicepain medicinediagnosticcommunicationmorphine hydrochloride
WA- 12 September 2014

Inquest into the Death of Peter Philip HUMES

38y · Male·Ligature compression of the neck (hanging)

Peter Philip Humes, a 38-year-old Aboriginal man, died by suicide by hanging in Hakea Prison while on remand. He was assessed by prison officer Trevena and nurse Lee on admission using the MR011 'At-Risk' checklist and d…

general practicecorrectional healthsystemdelaymirtazapine
VICcommunity2013-12-20

Finding into death of Kylie Anne Lightfoot

24y · Female·diabetic ketoacidosis in the setting of diabetes mellitus

Kylie Anne Lightfoot, a 24-year-old woman with type 1 diabetes, died from diabetic ketoacidosis. She presented to Dr S.'s practice on 4 May 2007 with abdominal pain, having not checked her blood sugar or taken insulin th…

general practiceendocrinologycommunicationsysteminsulin
VICcommunity2013-12-19

Finding into death of David Yannick Hollingsworth

29y · Male·Gunshot injury to the head

David Hollingsworth, a 29-year-old man with depression, died from a self-inflicted gunshot wound. He had expressed suicidal ideation to family members on 8 December 2012, contacted crisis services, and was observed actin…

psychiatrygeneral practicecommunicationsystemmirtazapine
VICaged care2013-12-18

Finding into death of Caterina Montalto

76y · Female·Immersion (with underlying cause undetermined in circumstances of a fall into a …

76-year-old woman with vascular dementia and wandering behaviour was found submerged in a courtyard water fountain at an aged care facility after a fall. She remained unattended in a hazardous area for approximately 51 m…

geriatric medicinegeneral practicecommunicationsystemdiazepam
QLD2013-12-11

Woods, Gavin Lyle

46y · Male·Consistent with exhaust fumes toxicity (suicide by carbon monoxide)

A 46-year-old teacher, Gavin Lyle Woods, died by suicide after prolonged workplace stress and an undertreated major depressive disorder. He had been a deputy principal at Burpengary State School for only five months. Cli…

psychiatrygeneral practicecommunicationsystemescitalopram
QLDhome2013-12-06

Cook, Jenny Lee

29y · Female·Exsanguination caused by a single stab wound to left lung

Jenny Lee Cook, age 29, died from a stab wound to the chest on 19 January 2009. Police concluded suicide within 20 hours but the investigation was fundamentally inadequate. Critical evidence was not obtained: Mr Cook's m…

forensic medicinepsychiatrydiagnosticsystemmirtazapine
VIChome2013-11-28

Finding into death of Deborah Kaye MacDonald

54y · Female·Complications of mixed drug toxicity (opiates, zolpidem, benzodiazepines and dox…

A 54-year-old woman with a history of PTSD, depression and suicidal ideation died from mixed drug toxicity (opiates, zolpidem, benzodiazepines, doxylamine). She had been accumulating prescribed medications over extended …

psychiatrygeriatric medicinesystemopiates
VICaged care2013-11-21

Finding into death of Ivo John Martinov

58y · Male·Unascertained causes

A 58-year-old man with treatment-resistant schizophrenia living in aged care died suddenly 30 minutes after receiving his evening clozapine dose. Although post-mortem toxicology detected a potentially toxic clozapine lev…

psychiatrygeneral practicesystemclozapine
NT2013-11-20

Inquest into the death of Sara Lorraine Hampel

21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…

Sara Hampel, 21 years old, died from sepsis caused by necrotising fasciitis (Group A Streptococcus) on 14 October 2011, presenting 8 days post-partum with severe leg pain and multiple signs of sepsis. Critical failures i…

obstetricsemergency medicinediagnosticcommunicationparacetamol
WAhospital2013-11-11

Inquest into the Death of Kerr

86y · Male·Acute Myocardial Ischaemia in an Elderly Man with Valvular and Ischaemic Heart D…

Henry Edwin Kerr, 86, died of acute myocardial ischaemia following left inguinal hernia surgery at Esperance District Hospital. He had significant cardiac history including valvular disease, ischaemic heart disease, and …

general surgeryanaesthesiacommunicationsystemglyceryl trinitrate
QLDcommunity2013-11-11

Pollini, Brett Andrew

43y · Male·Hanging

Brett Andrew Pollini, a 43-year-old fire station officer with bipolar affective disorder, died by suicide following a distressing telephone call with the Child Support Agency (CSA) regarding a substantial increase in chi…

psychiatrypsychologycommunicationsystemsodium valproate
TAS2013-11-06

Coroner's Finding: Sullivan, Craig

18y · Male·rupture of a left frontal cerebral abscess

An 18-year-old male detainee at Ashley Youth Detention Centre died from rupture of a left frontal cerebral abscess likely caused by sinus infection. Craig was admitted on remand in early October 2010 and presented with i…

infectious diseasesneurosurgerysystemdelay
VIChome2013-10-07

Finding into death of Imanthi Mayakaduwage

17y · Female·Hanging

Imanthi Mayakaduwage, a 17-year-old high-achieving international student from Sri Lanka, died by suicide via hanging on 5 May 2012. She had documented evidence of significant psychiatric distress from March 2012, includi…

general practicepsychiatrydiagnosticcommunication
QLD2013-10-04

Hempel, Barry Ian; Lovell, Ian Ross

Male·Multiple injuries from aircraft crash; underlying cause - epileptic seizure suff…

Two men died when a Yak-52 aircraft piloted by Barry Hempel crashed into the Pacific Ocean. Evidence suggests Hempel suffered an epileptic seizure mid-flight, rendering him incapacitated and unable to control the aircraf…

neurologyaviation medicinediagnosticcommunicationcarbamazepine
145464759

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