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VIChome2021-11-20

Finding into death of Mark Leslie Missen

56y · Male·Multiple blunt force trauma to the head and neck

This finding concerns the homicide of Mark Leslie Missen (56 years old) by his son Nathan in January 2016 following a family violence incident. The autopsy revealed death from multiple blunt force trauma to the head and …

systemcommunicationmethamphetamine
NSWcommunity2021-11-19

Inquest into the death of Huy Neng Ngo

57y · Male·penetrating injury to the neck sustained from a piece of metal propelled from a …

Mr Huy Neng Ngo, age 57, died on 13 July 2017 from a penetrating neck injury caused by a metal fragment propelled from a defective Takata airbag that ruptured during a minor motor vehicle collision. The vehicle's driver-…

communicationsystem
NSWhospital2021-11-19

Inquest into the death of Emiliana OBUSAN

1y · Female·unrecognised oesophageal intubation

A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of pe…

anaesthesiaorthopaedic surgerydiagnosticcommunicationfentanyl
NSWprison2021-11-19

Inquest into the death of Danny Whitton

25y · Male·Multiple organ failure due to acute paracetamol poisoning

Danny Whitton, a 25-year-old Aboriginal prisoner at Junee Correctional Centre, died from acute paracetamol toxicity causing multi-organ failure. He presented to the prison medical clinic on 5 November 2015 with vomiting …

emergency medicinetoxicologydiagnosticcommunicationparacetamol
ACTcommunity2021-11-15

Inquest into the death of Blake Andrew Corney

4y · Male·fatal head injury sustained as a passenger in a motor vehicle collision

Blake Corney, 4 years old, died from catastrophic head injuries when a heavy truck driven by Mr Akis Livas collided with his stationary family vehicle at an intersection. The driver had undiagnosed or unaddressed suspect…

systemcommunication
VICcommunity2021-11-11

Finding into death of Eden Herbert-Allan

33y · Male·Head injuries sustained in motor vehicle (tree fell on vehicle)

Eden Herbert-Allan, a 33-year-old man, died from head injuries when a tree fell on his vehicle on Warburton Highway. The tree had likely been compromised by water main replacement works (pipe cracking method) undertaken …

systemdelaymethamphetamine
NThome2021-11-09

Inquest into the death of Holly Davidson

38y · Female·Subdural haemorrhage in the context of chronic alcoholism due to post-traumatic …

Holly Anne Davidson, a 38-year-old police officer, died from a subdural haemorrhage sustained 3-5 days before her death. She had been in a coercive, controlling, and violent relationship with her police officer partner f…

emergency medicinepsychiatrydiagnosticsystemparacetamol/codeine/doxylamine
NSWhospital2021-11-09

Inquest into the death of Caitlin CRUZ

3y · Female·complications of Influenza B viral infection

Three-year-old Caitlin Cruz presented to a medical centre unwell and collapsed, requiring resuscitation. She was transferred by ambulance to Children's Hospital at Westmead but critical information about her collapse and…

emergency medicinepaediatricscommunicationdiagnosticmidazolam
VIChospital2021-11-08

Finding into death of Baby MNL

0y · Male·Hypoxic ischaemic encephalopathy complicating peri partum asphyxia

A term neonate died at 3 days of age from hypoxic ischaemic encephalopathy due to perinatal asphyxia. The mother presented in early labour, was initially discharged, then readmitted when labour progressed. Labour progres…

obstetricsneonatologysystemcommunicationterbutaline
NSW2021-11-08

Inquest into the death of Walter CLOUGH

66y · Male·Complications of chronic obstructive pulmonary disease. A significant contributi…

Walter Clough, aged 66, died from complications of COPD and cardiomegaly while incarcerated. He had significant respiratory compromise from prior chest trauma causing hemidiaphragm paralysis. Days before death, he was ho…

general practicerespiratory medicinesystemspriva
TASaged care2021-11-04

Coroner's Finding: Rosendale, Dwayne Edward

36y · Male·Complications of morbid obesity, including cardiac enlargement, aspiration of ga…

A 36-year-old man with treatment-resistant schizophrenia and Capgras syndrome died from complications of morbid obesity (183.5 kg, BMI 45.3). He was discharged from hospital on 14 January 2019 after admission for respira…

psychiatrygeneral medicinesystemdelayzuclopenthixol
SA2021-11-04

Coroner's Finding: Papageorgiou, Theo Nickolas

27y · Male·compression of the neck due to hanging

Theo Papageorgiou, a 27-year-old man with a history of psychotic and manic symptoms since November 2014, was briefly detained under a mental health order in November 2015 but discharged after only six days despite contin…

psychiatrygeneral practicediagnosticcommunicationolanzapine
WAprison2021-11-01

Inquest into the Death of Joseph Thomas ROE

50y · Male·subarachnoid and intracerebral haemorrhage in association with a ruptured berry …

Joseph Thomas Roe, age 50, died from a ruptured berry aneurysm causing subarachnoid and intracerebral haemorrhage. He was a prisoner at Casuarina Prison when he called for medical assistance on the night of 17-18 Septemb…

emergency medicineneurosurgerycommunicationsystem
QLDhospital2021-11-01

Masoumali, Omid

24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns

Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement.…

plastic and reconstructive surgeryintensive carecommunicationsystem
NSWPodcast2021-10-29

Inquest into the death of Jesse DRABSCH

31y · Male·Hypoxic brain injury caused by the exogenous administration of insulin, resultin…

Jesse Drabsch, 31, died from hypoglycaemia after self-injecting insulin in a gym bathroom. A competitive bodybuilder using performance and image enhancing drugs (PIEDs), Jesse entered the bathroom at 5:30pm on 16 Novembe…

endocrinologytoxicologysystemproceduralinsulin
VIChome2021-10-28

Finding into death of Yunjie Zhang

20y · Female·Complications of malnutrition in the setting of presumed nitrous oxide use

A 20-year-old university student living alone in Melbourne died between 28 July and 7 August 2020 from complications of malnutrition in the setting of presumed nitrous oxide use. Thousands of nitrous oxide canisters were…

forensic medicinepublic healthsystemnitrous oxide
NSW2021-10-25

Inquest into the death of Bronwynne RICHARDSON

17y · Female·Pressure to the neck (strangulation) and drowning

This is a coronial finding into the 1973 death of Bronwynne Anne Richardson, a 17-year-old found in Horseshoe Lagoon with injuries consistent with strangulation and drowning. She had been abducted from Albury, NSW and ph…

communicationsystem
VIChome2021-10-23

Finding into death of Mr C

56y · Male·Ischaemic Heart Disease and Coronary Artery Atherosclerosis

A 56-year-old man with a history of coronary artery disease and stenting presented to his GP on 17 February 2020 with right upper quadrant discomfort. The GP did not consider a cardiac source, attributing symptoms to abd…

general practicecardiologydiagnosticsystem
WAmental health2021-10-22

Inquest into the Death of Russell David BROCKLISS

38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…

Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute car…

psychiatryemergency medicinedelaysystemrisperidone depot
NSW2021-10-22

Inquest into the death of A

34y · Male·hanging

A 34-year-old man died by hanging in a correctional centre in December 2018. He was placed on a mental health waitlist in June 2018 but was never seen by a mental health nurse due to insufficient staffing—only 1.5 FTE po…

forensic medicinepsychiatrycommunicationsystem

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