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WAhome2021-08-10

Inquest into the Death of Scott William MARTIN

40y · Male·Penetrating wounds to the chest

Scott William Martin, aged 40, was fatally stabbed in his apartment in Halls Head, Western Australia in January 2017 by Damian Maxfield, who was experiencing a methamphetamine-induced psychotic episode. Maxfield had been…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
TAS2021-08-09

Coroner's Finding: Negga, Retbe Chide

50y · Male·blunt trauma of the abdomen, pelvis and legs

Retbe Chide Negga, an Ethiopian-born seasonal farm worker, died from crush injuries after his leg became trapped beneath a trailer wheel while attempting to board a moving tractor-trailer at a cherry orchard. Key clinica…

trauma surgeryemergency medicinesystemcommunicationketamine
VIChome2021-08-04

Finding into death of NB

1y · Male·Global cerebral ischaemia in an infant with upper airway obstruction

NB, a 14-month-old with a tracheostomy requiring overnight nursing support in foster care, suffered a cardiac arrest on 17 December 2016 that resulted in severe hypoxic brain injury and death. The overnight nurse (Ms Jar…

respiratory medicineintensive carediagnosticcommunication
VIChome2021-08-03

Finding into death of Ashley Wayne Phillips

44y · Male·Strangulation

Ashley Phillips, aged 44, was strangled to death by Jason Considine during a consensual sexual encounter on 26 May 2017. This finding reveals systemic failures in community corrections case management. Considine was subj…

correctional healthforensic medicinesystemcommunicationmethamphetamine
VIChome2021-08-03

Finding into death of V T

75y · Female·Multiple injuries including stab wounds to the chest

A 75-year-old woman was fatally stabbed by her son during a family violence incident. Her son had a 20-year history of schizophrenia and schizoaffective disorder with poor medication compliance, documented aggression tow…

psychiatrygeneral practicecommunicationsystem
ACTcommunity2021-08-02

Inquest into the death of KATHLEEN BAIN HENDERSON

85y · Female·Head injury due to a fall from a bus

An 85-year-old woman died from a serious head injury sustained when she fell backwards from a community transport bus. She fell through the open side door onto the concrete driveway after standing to exit. The coroner fo…

system
WAhospital2021-07-30

Inquest into the Death of Chad RILEY

39y · Male·Cardiac arrhythmia following violent exertion necessitating physical restraint i…

39-year-old Chad Riley died from cardiac arrhythmia following violent exertion during physical restraint. He presented to hospital intoxicated with methylamphetamine, exhibiting drug-induced psychosis with agitation and …

emergency medicinepsychiatrysystemmethamphetamine
NSWcommunity2021-07-30

Inquest into the death of A J

36y · Male·multiple injuries consistent with a fall from a height

A 36-year-old man with severe depression, social isolation, and recent life crises (job loss, marital breakdown, reduced child contact) posted suicidal messages on social media and stood on a cliff ledge. Police negotiat…

psychiatrycorrectional healthcommunicationdelaysertraline
TAS2021-07-27

Coroner's Finding: Selby, Robert Norman

75y · Male·Crush injuries of the chest and pelvis sustained when overrun by a tractor

A 75-year-old experienced farmer died from crush injuries sustained when run over by a Ford 4000 tractor. While attempting to dislodge a hay bale from the tractor spike with a neighbour, Mr Selby engaged the tractor's ge…

proceduralsystem
VIChome2021-07-27

Finding into death of Daniel Joseph Herbert

37y · Male·Combined drug toxicity (methadone, fentanyl, diazepam and pregabalin)

Daniel Joseph Herbert, aged 37, died from combined drug toxicity involving methadone, fentanyl, diazepam and pregabalin. He had a 17-year history of opioid dependence stemming from prescription OxyContin for a work-relat…

general practiceaddiction medicinecommunicationsystemmethadone
TAShospital2021-07-26

Coroner's Finding: Sowden, James Robert

65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists

James Robert Sowden, aged 65, died by self-inflicted neck and wrist wounds on 28-29 March 2018. He had a history of depression with paranoid features (diagnosed 2003) and autoimmune thyroiditis. In the week before death,…

psychiatryemergency medicinediagnosticcommunicationquetiapine
QLD2021-07-26

Cunningham, Luke

21y · Male·Hanging

Luke Cunningham, aged 21, died by hanging in a prison cell at Arthur Gorrie Correctional Centre in Queensland in September 2018. He was on remand facing murder charges. An initial psychological assessment upon reception …

psychiatrycorrectional healthsystem
VICcommunity2021-07-26

Finding into death of Adam Laufer

32y · Male·Multiple injuries sustained in a fall from a height

Adam Laufer, a 32-year-old man with longstanding bipolar disorder, died by suicide on 24 November 2016 when he jumped from the LaTrobe Street overpass in Melbourne. In the early hours of 24 November, his father called tr…

psychiatrypsychologysystemcommunication
VIChospital2021-07-22

Finding into death of Christian Joy

34y · Male·Cardiac tamponade due to hemopericardium from acute aortic dissection of the asc…

A 34-year-old previously healthy man presented to the ED with sudden-onset central chest pain. He was discharged with a diagnosis of GORD after negative troponin and symptomatic relief with antacids. A chest X-ray showed…

emergency medicineradiologydiagnosticcommunicationmorphine
VIChospital2021-07-20

Finding into death of Barry Brown

56y · Male·Internal blood loss, complications arising from laparoscopic cholecystectomy

Barry Brown, a 56-year-old man, died from internal bleeding after laparoscopic cholecystectomy due to critical systemic failures in post-operative care and diagnosis. Following hypotension at 7:30pm, nursing staff failed…

general surgeryintensive carediagnosticcommunicationnoradrenaline
NSW2021-07-15

Findings into the death of MH

22y · Male·Hanging

A 22-year-old man with severe chronic treatment-resistant schizophrenia and substance use disorder died by hanging in prison custody. He had been recently discharged from a mental health hospital to police custody follow…

psychiatrycorrectional healthdiagnosticsystemzuclopenthixol
VIChome2021-07-14

Finding into death of Edward Michael Espino

36y · Male·neck compression in the circumstances of hanging

Edward Espino, a 36-year-old man with bipolar affective disorder, died by hanging on 1 February 2016. In the hours preceding his death, he learned of a police 'whereabouts' alert placed six months after a minor assault a…

psychiatryforensic medicinesystemsodium valproate
VIChospital2021-07-13

Finding into death of Simone Grigg

34y · Female·Pneumonia in a woman with intellectual disability and asthma

Simone Grigg, a 34-year-old woman with intellectual disability and asthma, died from pneumonia. She was living in DHHS supported accommodation and attending Amicus day services. On 21 November 2017, she developed respira…

emergency medicineintensive carecommunicationdelayhay fever medication
VICcommunity2021-07-13

Finding into death of Richard Powell

32y · Male·Head injuries sustained in a motor vehicle incident (pedestrian)

Richard Powell, a 32-year-old with a history of violent behaviour and methamphetamine use, died from head injuries sustained in a motor vehicle incident while assaulting his domestic partner. This case reveals critical f…

diagnosticsystemmethamphetamine
NSWhome2021-07-07

Inquest into the death of Kimberley APPLEBY

56y · Female·acute pentobarbitone toxicity

56-year-old woman died from acute pentobarbitone toxicity in her Sydney apartment on 27-28 May 2016. She had a long history of mental health issues, depression, substance use, and prior self-harm. She had recently obtain…

psychiatrypsychologysystemproceduralpentobarbitone

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