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TASaged care2023

Coroner's Finding: Tweedie, Valma Ann

72y · Female·Pneumonia following cervical spine injuries sustained in an unwitnessed mechanic…

Valma Ann Tweedie, aged 72, died from pneumonia following cervical spine injuries sustained in an unwitnessed fall at a disability support facility. She had a known history of falls, mobility problems, and probable demen…

emergency medicinetrauma surgerydiagnosticcommunication
NTcommunity2023

Inquest into the death of Toddler R

3y · Male·Disseminated Staphylococcus aureus infection

A 3-year-old Aboriginal boy died from disseminated Staphylococcus aureus infection with sepsis. He presented to a remote clinic on 10 April with fever and dizziness, then returned on 13 April with irregular fever, lethar…

general practicepaediatricsdiagnosticdelayparacetamol
VIChome2023

Finding into death of Mr ZJF

27y · Male·Dextromethorphan toxicity

Mr ZJF, a 27-year-old man with a longstanding history of schizophrenia, polysubstance use disorder, and depression, died from dextromethorphan toxicity. He was subject to a Community Treatment Order at the time of death …

psychiatrygeneral practicesystemdextromethorphan
VICcommunity2023

Finding into death of Ms KSQ

39y · Female·Plastic bag asphyxia

Ms KSQ, aged 39, died by plastic bag asphyxia in May 2023. She had experienced alleged sexual abuse and coercive control from her partner over 12 years. In September 2022, when she attempted to change locks at the family…

diagnosticsystemclobazam
VIChospital2022-12-22

Finding into death of Paige Dent

25y · Female·Injuries sustained in a single vehicle motor vehicle incident in which Ms Dent w…

Paige Dent, 25, died in a single-vehicle motor accident after absconding from hospital on 6 October 2018. She had a 19-year history of psychiatric admissions for schizophrenia, borderline personality disorder, and substa…

psychiatryemergency medicinesystemcommunicationmethamphetamine
VICmental health2022-12-21

Finding into death of Kai Wesley Wu

23y · Male·Injuries sustained when struck by train

Kai Wu, a 23-year-old man with first-episode psychosis, died by suicide at a railway station while on escorted leave from psychiatric inpatient care. He had been admitted to The Alfred Hospital in January 2018 under Ment…

psychiatrycommunicationsystemhaloperidol
NSWhospital2022-12-21

Inquest into death of Andrea LESTER

49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…

Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfu…

neurosurgeryintensive carediagnosticcommunicationtramadol
VIChome2022-12-20

Finding into death of Wei Hu

40y · Male·Stab wound to the chest

Wei Hu, a 40-year-old IT engineer, died from a stab wound to the chest inflicted by himself following a fatal incident involving intimate partner violence. The death occurred after Mr Hu stabbed his wife Ms Zhou and then…

general practicepsychiatrycommunicationsystem
VICcommunity2022-12-20

Finding into death of Charles Frederick Norton

87y · Male·Ischaemic heart disease in the setting of immersion

Charles Frederick Norton, 87, was found deceased in an unsecured canal at a retirement village on 28 February 2020. He had ischaemic heart disease with severe atherosclerosis and aortic stenosis. In the week before death…

general practiceemergency medicinesystemdiltiazem
SAhome2022-12-16

Coroner's Finding: Reid, Paul

50y · Male·ischaemic heart disease

Paul Reid, a 50-year-old Aboriginal man with severe ischaemic heart disease and poor medication compliance, died of a cardiac arrhythmia during his arrest by South Australian Police. He was highly intoxicated (BAC 0.25%)…

cardiologyforensic medicinediagnosticsystemalcohol
NSW2022-12-15

Inquest into the death of YAKAMURRO - Findings

15y · Male·Neck compression due to hanging

Yakamurro, a 15-year-old First Nations boy in Territory Families care, died by hanging in NSW in December 2018. The coroner found multiple systemic failures contributed to his death. Key failures: inadequate family consu…

systemcommunication
VICmental health2022-12-15

Finding into death of Christopher Traill

55y · Male·Hanging

Christopher Traill, a 55-year-old lawyer with alcohol dependence and depression, died by hanging in a psychiatric inpatient unit on 25 February 2017, just hours after admission as a compulsory patient. He used his belt a…

psychiatryproceduralcommunicationdiazepam
VIChome2022-12-15

Finding into death of Taylor Zachary Oliver

19y · Male·Stab wounds to the neck and chest

Taylor Oliver, a 19-year-old with schizophrenia and substance use disorder, died by self-inflicted stab wounds on 1 December 2019. He had been admitted to mental health inpatient care on 18 November 2019 following overdo…

psychiatryemergency medicinecommunicationsystempaliperidone
VIC2022-12-15

Finding into death of Robert Wayne Edwards

61y · Male·INJURIES SUSTAINED IN A BOAT COLLISION

Robert Wayne Edwards, 61, died from injuries sustained in a boat collision on Gippsland Lakes. While both vessels were underway at similar speeds, Edwards' vessel was positioned on the port side of the channel contrary t…

system
VICmental health2022-12-15

Finding into death of Kira Shae James

21y · Female·Neck compression

Kira Shae James, a 21-year-old with psychosis, borderline personality disorder, and eating disorder, died by ligature at Thomas Embling Hospital while an involuntary inpatient under Mental Health Act orders. She had a le…

psychiatrypsychologyproceduralcommunication
WAprison2022-12-13

Inquest into the Death of William Frederick ANDERSON

53y · Male·intracerebral haemorrhage

William Anderson, an Aboriginal man aged 53, suffered a catastrophic intracerebral haemorrhage while imprisoned and died despite timely emergency response. Multiple delays occurred: 25 minutes before the cell was opened,…

emergency medicineneurologydelaysystemaspirin
VIChome2022-12-13

Finding into death of Patricia Backhurst

82y · Female·unascertained

Patricia Backhurst, an 82-year-old woman with dementia, disappeared from her home in Inverloch, Victoria on 18 March 2021. She had been diagnosed with Alzheimer's disease in February 2020 and showed progressive cognitive…

geriatric medicinesystem
VICmental health2022-12-12

Finding into death of Scott Adam Brown

50y · Male·Hanging

A 50-year-old man with Parkinson's disease died by hanging in a psychiatric inpatient unit while on a Temporary Treatment Order. His mental and behavioural symptoms were secondary to Parkinson's disease and its treatment…

psychiatryneurologysystemcommunicationmadopar
VICaged care2022-12-12

Finding into death of Lorraine Earl

71y · Female·Complications of cerebral palsy

Lorraine Earl, aged 71, died from complications of cerebral palsy at Wantirna Hospital following a palliative care pathway initiated after severe dysphagia developed during a hospital admission. The Disability Services C…

palliative caregastroenterologycommunicationsystem
NSW2022-12-09

Inquest into the death of Tyrone Adams

22y · Male·Multiple injuries to the chest, abdomen and limbs

Tyrone Adams, age 22, died in a motor vehicle collision on the M1 Motorway following a police pursuit. The initial pursuit was initiated based on questionable reasonable suspicion to stop a hire vehicle. The coroner foun…

proceduralcommunicationmethamphetamine

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