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NSWhospital2021-04-16

Inquest into the death of Kelvin MOULDS

61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a c…

Kelvin Moulds, a 61-year-old man, died of hypoxic encephalopathy following a cardiac arrest caused by self-removal of a central venous catheter (CVC) on day 14 post-bilateral lung transplant. The CVC was still in situ de…

cardiothoracic surgerytransplant medicinecommunicationsystemoxycodone
SAhome2021-04-15

Coroner's Finding: WOODFORD Gayle Elizabeth

56y · Female·multiple blunt force injuries deliberately inflicted

Gayle Elizabeth Woodford, a 56-year-old registered nurse working in Fregon, APY Lands, was abducted and murdered on 23 March 2016 by Dudley Davey, who had a long history of violent sexual offences dating back to age 14. …

occupational and environmental healthemergency medicinesystemcommunication
VICcommunity2021-04-14

Finding into death of JJ

70y · Male·Hanging

A 60-year-old man with recent pituitary surgery developed persistent fatigue and depressive symptoms. Despite normal cortisol levels, he remained convinced his symptoms were due to hormonal deficiency rather than depress…

psychiatryendocrinologycommunicationsystemvenlafaxine
VIChome2021-04-13

Finding into death of Jason Leslie Smith

44y · Male·Gunshot wound to the head

Jason Smith, 44, was shot in the head by his uncle John Pozzebon in a family violence incident. The coroner found that while Pozzebon had a valid firearms license, his mental health had deteriorated significantly followi…

general practiceforensic medicinecommunicationsystem
TAShospital2021-04-12

Coroner's Finding: Fowler, Alice Mary

91y · Female·Pelvic haematoma complicating a fracture of the neck of the left femur

Mrs Fowler, a 91-year-old woman with dementia, poor hearing, and documented high fall risk, was admitted to Royal Hobart Hospital after a home fall. She fell from her hospital bed on 4 December 2015, fracturing her hip a…

geriatric medicineorthopaedic surgerysystemdelay
VIChospital2021-04-08

Finding into death of Ian Lindsay Gould

64y · Male·Complications of Creutzfeldt-Jakob Disease following a fall

Ian Gould, a 64-year-old man with a non-MRI compatible pacemaker, presented with vision loss in June 2019. Initial neurological and ophthalmological evaluation was normal; functional visual loss was suspected. He develop…

neurologyophthalmologysystemrivaroxaban
VIChospital2021-04-07

Finding into death of Anson

17y · Male·mixed drug toxicity (25C-NBOMe and 4-fluoroamphetamine)

A 17-year-old male died from mixed drug toxicity involving 25C-NBOMe and 4-fluoroamphetamine after consuming a substance he believed was MDMA or psilocybin, obtained from unregulated drug markets. He experienced severe s…

emergency medicineintensive caresystemdelay25c-nbome
NSWhome2021-04-07

Inquest into the deaths of John, Jack and Jennifer EDWARDS

Multiple gunshot wounds to the head, chest, abdomen and extremities (Jennifer); …

Two children, Jack (15) and Jennifer (13), were fatally shot by their father John Edwards at their home on 5 July 2018. John had a 35-year history of family violence across multiple relationships, with documented evidenc…

diagnosticsystem
NTcommunity2021-04-01

Inquest into the death of Patrick Bloomfield

42y · Male·Blunt force head and chest injuries caused by a traffic crash where he was the d…

Patrick Wayne Bloomfield, a 42-year-old Aboriginal man, died from blunt force head and chest injuries when his vehicle rolled on the Plenty Highway after police initiated a pursuit from a random breath testing (RBT) stat…

emergency medicineforensic medicinesystemcommunication
VICcommunity2021-03-31

Finding into death of Ilker

32y · Male·Mixed drug toxicity (25C-NBOMe, 4-fluoroamphetamine, doxylamine)

A 32-year-old man died from mixed drug toxicity after consuming tablets he believed were MDMA, which actually contained 25C-NBOMe and 4-fluoroamphetamine—novel psychoactive substances (NPS) of unknown potency obtained fr…

emergency medicinetoxicologysystem25c-nbome
VIChome2021-03-31

Finding into death of Jason

30y · Male·Mixed drug toxicity (4-Fluoroamphetamine, 25C-NBOMe, dimethylamphetamine, methyl…

Jason, aged 30, died from mixed drug toxicity after ingesting what he believed to be MDMA but which actually contained 25C-NBOMe and 4-fluoroamphetamine, combined with GHB. He experienced seizures and collapsed; CPR was …

toxicologyforensic medicinesystem25c-nbome
VIChome2021-03-31

Finding into death of Jordan

22y · Male·Hypoxic/ischaemic encephalopathy secondary to restraint in the context of combin…

A 22-year-old male died from hypoxic-ischaemic encephalopathy following restraint during acute intoxication with novel psychoactive substances (NPS). He unknowingly ingested 25C-NBOMe and 4-fluoroamphetamine (sold as MDM…

toxicologyintensive caresystemdelay25c-nbome
NSWhome2021-03-31

Inquest into the death of John Glen LAURENSON

47y · Male·sequelae of ruptured brain aneurysm

John Laurenson, a 47-year-old remand prisoner, died from rupture of a brain aneurysm on 20 June 2017, four days after collapsing in his prison cell. He had multiple intracranial aneurysms identified in 2015-2016, includi…

neurosurgerygeneral practicediagnosticcommunication
VIC2021-03-30

Finding into death of MRE

12y · Male·Traumatic head injuries

A 12-year-old boy died from traumatic head injuries while attempting to repair a spreader conveyor belt using a metal bar while the tractor and spreader were in motion on a farm. He fell under the spreader wheel and was …

system
VIChospital2021-03-30

Finding into death of Mr BB

56y · Male·Hanging

A 56-year-old man with a long history of bipolar affective disorder and alcohol misuse died by hanging between 18–20 December 2018. He presented to hospital on 16 December after expressing suicidal intent (plan to overdo…

psychiatryemergency medicinecommunicationsystemdiazepam
WAhospital2021-03-26

Inquest into the Death of Cyril CHURCHILL

68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…

Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treatin…

general surgeryanaesthesiadiagnosticcommunication
WAhome2021-03-25

Inquest into the Death of FJ (Name Subject to Suppression Order)

35y · Female·multiple injuries sustained in fall from sixth-floor balcony

FJ, an Iranian woman with bipolar affective disorder and schizophrenia, died by suicide at age 35 in November 2016. Key clinical lessons include: (1) the critical importance of continuity of psychiatric care during trans…

psychiatrygeneral practicecommunicationsystemlithium
VIChospital2021-03-19

Finding into death of BT

25y · Male·Multiple system failure and ingestion of sodium nitrite

BT, a 25-year-old man with bipolar affective disorder and long-standing depression, died from intentional sodium nitrite ingestion while an inpatient in the Behavioural Assessment Unit at Royal Melbourne Hospital. He pre…

emergency medicinepsychiatrydiagnosticsystemsodium nitrite
VIC2021-03-18

Finding into death of Stanley Bruce Weaver

61y · Male·Hanging

Stanley Bruce Weaver, a 61-year-old firefighter with a history of depression and previous suicide attempts, died by hanging at his workplace on 26 August 2019. His wife had reported concerns about medication stockpiling …

psychiatrygeneral practicesystemdiazepam
NSWhome2021-03-17

Findings Becky

15y · Female·methylamphetamine and methadone toxicity

Becky, aged 15, died on 26 March 2016 from methylamphetamine and methadone toxicity at a private residence in Armidale, NSW. She was in the parental responsibility of the Department of Family and Community Services (FACS…

social workcommunicationsystemmethamphetamine

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