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VIChospital2022-01-20

Finding into death of Ann-Maree Manno

57y · Female·Pulmonary thromboembolism

Ann-Maree Manno, 57, died from pulmonary thromboembolism 8 days after laparoscopic gastric band surgery. She had significant risk factors: obesity (BMI 37.9), history of unprovoked DVT in 2007 and 2016, and recent surger…

bariatric surgeryanaesthesiacommunicationsystemheparin
VIChospital2022-01-20

Finding into death of H I

49y · Female·Acute myocardial infarction secondary to giant-cell arteritis and atherosclerosi…

49-year-old woman died from acute myocardial infarction secondary to giant-cell arteritis of coronary arteries. On 26 November, she presented to her GP with left-sided chest pain described as atypical and unlikely ischae…

general practiceemergency medicinediagnosticsystemmetoclopramide
VIC2022-01-19

Finding into death of Thi Minh Tam Nguyen

62y · Female·Drowning

A 62-year-old woman drowned after a recreational fishing boat sank in Port Phillip Bay. The vessel, a modified 1980s Huntsman, had multiple structural deficiencies including corroded hull below bungs allowing water ingre…

systemprocedural
QLDhome2022-01-18

Lewis, Daniel Patrick

36y · Male·Gunshot wounds to the chest and abdomen

Daniel Lewis, aged 36, died from gunshot wounds after police responded to a domestic violence call. Lewis had a history of brain injury from age 11, substance abuse, mental health issues including PTSD and drug-induced p…

psychiatryemergency medicinecommunicationsystemalcohol
WAhospital2022-01-17

Inquest into the Death of Peter Johnnie YOUNG

Male·Complications of alcohol and hepatitis C-related liver disease

Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…

hepatologygastroenterologysystemdelayquetiapine
WAhome2022-01-17

Inquest into the Death of Shaun Andrew WILLIS

54y · Male·Ligature compression of the neck (hanging)

Shaun Willis, aged 54, died by hanging at his home on 8 March 2019 following a turbulent separation and family violence history. He was arrested on 7 March for assaulted his ex-wife and served with a Family Violence Rest…

communicationsystemalcohol
VICaged care2022-01-14

Finding into death of Margaret Lillian Watkins

84y · Female·Complications of pelvic fractures sustained in a traumatic incident

An 84-year-old woman with dementia died from complications of pelvic fractures sustained when another dementia-affected resident pushed her during an altercation over food in an aged care facility. She developed bilatera…

geriatric medicineemergency medicinesystemdelaymorphine
VIC2022-01-14

Finding into death of VP Z

35y · Male·Head injuries sustained in an explosion

A 35-year-old diesel mechanic died from head injuries sustained in an explosion while attempting to cut a hole in a used 10,000-litre diesel tank at his parents' property. The tank contained residual diesel and had not b…

proceduralsystem
VIChome2022-01-12

Finding into death of Linda-Jane Margaret Tatterson

40y · Female·combined drug toxicity (clomipramine, sertraline, diazepam, and quetiapine)

Linda-Jane Tatterson, aged 40, died from combined drug toxicity involving clomipramine, sertraline, diazepam, and quetiapine. She had a longstanding history of depression, OCD, and recurrent overdoses between 2014-2016. …

general practicepsychiatrycommunicationsystemclomipramine
QLDcommunity2022-01-11

Noombah

39y · Male·Cardiac arrest in a person with pre-existing severe ischaemic heart disease who …

A 39-year-old First Nations man with severe ischaemic heart disease died following police restraint and ambulance care during an emergency examination authority detention. He had sniffed petrol and threatened self-harm; …

emergency medicineparamedicinediagnosticcommunicationpetrol
VIChome2022-01-10

Finding into death of Deborah Marie Holtkamp

52y · Female·Mixed drug toxicity

Deborah Marie Holtkamp, 52, died from mixed drug toxicity in July 2018 in circumstances consistent with suicide. She had a long history of depression, childhood abuse trauma, chronic pain conditions, and recent relations…

general practicepsychiatrydiagnosticcommunicationmorphine
WAhospital2022-01-05

Inquest into the Death of Terrence Alexander Penman WELLS

61y · Male·metastatic oesophageal neuroendocrine carcinoma

Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attribut…

oncologypalliative caremedicationsystempantoprazole
VIChome2022-01-03

Finding into death of Patricia Jocelyn Eve Grant

83y · Female·Aspiration bronchopneumonia in a setting of cerebral infarction

Ms Patricia Grant, 83, died from aspiration bronchopneumonia following cerebral infarction while living with her son and daughter-in-law. She experienced severe neglect and elder abuse in her final years: cessation of ep…

general practicegeriatric medicinediagnosticsystem
VICmental health2022

Finding into death of LKV LKV

73y · Male·Neck compression in the circumstances of hanging

A 73-year-old man with severe depression and suicidal ideation died by hanging at a private psychiatric facility on 9 February 2019 during voluntary admission. He was assessed as low risk despite recent suicidal statemen…

psychiatrygeneral practicediagnosticsystemescitalopram
VIChome2022

Finding into death of M D

46y · Male·injuries sustained in a deer attack

A 46-year-old man died from massive injuries sustained during a deer attack on his property in regional Victoria. The male Wapiti deer, which the family had raised from a fawn, was in rutting season (late March to April)…

system
VIChome2022

Finding into death of TCW

43y · Female·Neck compression

TCW, age 43, died from neck compression inflicted by her adult son OMP (age 17 at time of incident, now convicted of manslaughter). OMP had intellectual disability (IQ 59), autism spectrum disorder, and hypersexual disor…

psychiatrypsychologysystemdelayfluoxetine
NSWcommunity2021-12-23

Inquest into the deaths of Judith CHRUPALO and Christopher CLEE

73y · Female·Unknown due to decomposition

Mrs Chrupalo, a 73-year-old woman with physical disability, cognitive impairment and alcohol dependency, was discharged from Dubbo Base Hospital on 8 July 2015 against medical advice despite being bedbound and dependent …

geriatric medicinepsychiatrydiagnosticcommunication
NSWhospital2021-12-23

Inquest into the death of Shelley YOUNG

65y · Female·choking on a tangerine

Ms Shelley Young, a 65-year-old woman with long-standing schizoaffective disorder and multiple complications from chronic antipsychotic use including dysphagia and tardive dyskinesia, died from choking on a tangerine whi…

psychiatrygeriatric medicinecommunicationsystemclozapine
WA2021-12-22

Inquest into the Death of Brett Ashley DUTURBURE

29y · Male·ligature compression of the neck (hanging)

Brett Ashley Duturbure, aged 29, died by suicide via hanging at Wyndham Work Camp on 14 November 2019. The coroner identified critical systemic failures in the Department of Justice's management of his care. The Departme…

correctional healthpsychiatrysystemcommunication
NSW2021-12-22

Inquest into the death of Jack LOH

Male·Unrecognised pulmonary hypertension in a setting of unsafe sleeping conditions

Jack Loh, a 6-month-old boy, died from unrecognised pulmonary hypertension while in unsafe sleeping conditions at a family day care centre. Jack was placed prone (face down) in an undersized bassinet with loose bedding m…

cardiologypathologysystemdelay

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