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WAhospital2021-02-09

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

0y · Female·head and neck injuries

A 4-month-old girl (Baby H) died from head and neck injuries caused by violent shaking inflicted by her mother on 28 May 2017. She had presented to an emergency department on 10 May 2017 with facial bruising, which physi…

emergency medicinepaediatricsdiagnosticcommunication
NSWhospital2021-02-08

Inquest into the death of Simone O'Donnell

24y · Female·Cardiac conducting system disease leading to asystole against a background of a …

A 24-year-old woman with complex congenital cardiac disease, cerebral palsy, and hydrocephalus was admitted to a secondary hospital with a respiratory tract infection and bradycardia with left bundle branch block. She de…

cardiologyemergency medicinesystemcommunicationoxycodone
TAShospital2021-02-05

Coroner's Finding: Lattimer, Joseph Aaron

37y · Male·hypoxic encephalopathy due to asphyxia from hanging

Joseph Aaron Lattimer, aged 37, presented to the Royal Hobart Hospital Emergency Department at 5:02am on 10 July 2016 in mental health crisis with suicidal ideation, correctly triaged as Category 3 (urgent, requiring ass…

emergency medicinepsychiatrysystemdelayalcohol
VIChospital2021-02-05

Finding into death of Carl David Waldon

64y · Male·Left-sided intracerebral haemorrhage associated with deep brain stimulator wire …

A 64-year-old man died from intracerebral haemorrhage along a deep brain stimulator wire tract four days after elective neurosurgery for essential tremor. He was readmitted on day 4 with suspected stroke and started on t…

neurosurgeryneurologymedicationsystemenoxaparin
QLDhospital2021-01-27

Brown, Tara Matekino - Non-inquest findings

24y · Female·Head injury from repeated blunt force trauma

A 24-year-old woman was fatally assaulted by her intimate partner after a period of escalating domestic and family violence. The perpetrator had a documented history of violent DFV across multiple relationships, with pri…

emergency medicineintensive carediagnosticcommunication
TAS2021-01-22

Coroner's Finding: Buhler, Finn Ruben Leo

19y · Male·traumatic head injury sustained in a single motor vehicle collision

A 19-year-old German national on a working holiday visa died from traumatic head injury sustained in a single-vehicle motor crash on a remote gravel road in Tasmania. His vehicle lost control on a curve with a critical s…

system
QLD2021-01-22

Miller, Cindy Leigh

44y · Female·Mixed drug toxicity (methylamphetamine, amphetamine, tramadol)

Cindy Leigh Miller, aged 44, died in Ipswich Watchhouse on 21 April 2018 from mixed drug toxicity involving methylamphetamine, amphetamine, tramadol and other substances. A concealed clip-seal bag containing 5mg pure met…

forensic medicineemergency medicinesystemproceduralmethamphetamine
QLDhome2021-01-22

Cobb, Tyrell - Non-inquest findings

4y · Male·Intra-abdominal injuries from blunt force trauma (ruptured duodenum and lacerate…

Tyrell Cobb, a 4-year-old boy, died from intra-abdominal injuries caused by blunt force trauma inflicted on two separate occasions between 22-24 May 2009. Postmortem revealed a ruptured duodenum and lacerated mesentery c…

paediatricsemergency medicinedelaysystem
QLDhospital2021-01-20

Palhares, Fabiana - Non-inquest findings

34y · Female·Head injuries from blunt force trauma (multiple blows from axe); abdominal injur…

A 34-year-old pregnant woman died from severe head and abdominal injuries inflicted by her estranged partner in a domestic violence homicide. The death followed escalating domestic and family violence (DFV) including phy…

emergency medicinepsychiatrydiagnosticcommunicationmirtazapine
VIChome2021-01-20

Finding into death of Mitchell James Dowling

20y · Male·Hanging

Mitchell Dowling, a 20-year-old university student, died by hanging on 18 July 2018 after a period of psychological treatment for depression with suicidal ideation. He had presented with major depressive disorder with at…

psychologypsychiatrycommunicationsystemalcohol
WAhospice2021-01-15

Inquest into the Death of Stuart William DUGAN

70y · Male·carcinoma of the lung

Stuart Dugan, a 70-year-old prisoner with advanced lung cancer, died in hospice care. He had multiple missed opportunities for earlier diagnosis. While smoking-related lung cancer commonly presents late with poor prognos…

general practicerespiratory medicinediagnosticcommunicationtramadol
NT2021-01-15

Inquest into the death of Christopher Malyschko

31y · Male·positional asphyxia due to synthetic cannabis use and obesity

Christopher Mark Malyschko, a 31-year-old male imprisoned for life, died in a Northern Territory prison cell from positional asphyxia caused by synthetic cannabis (Kronic) use combined with obesity. Clinical and systemic…

forensic medicinetoxicologysystemdelaycumyl-pegaclone
VIC2021-01-14

Finding into death of Allan Russell McFarlane

71y · Male·cardiac arrest secondary to near drowning

A 71-year-old experienced boatman died from cardiac arrest following near drowning when a borrowed boat capsized in Port Phillip Bay. The vessel (MA827) had multiple design and maintenance issues: low freeboard unsuitabl…

emergency medicineintensive caresystemmidazolam
VIC2021-01-13

Finding into death of Nguyen Pham Dinh Le

21y · Male·Injuries sustained in a fall from a height

A 21-year-old Vietnamese international student died by suicide, jumping from the 10th floor of a university building. He was not known to university health or counselling services and had no documented contact with Austr…

psychiatrypublic healthsystemcommunication
VIChome2021

Finding into death of Tate Hobbs

36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)

A 36-year-old motor mechanic with chronic pain from a 2014 knee injury died from combined drug toxicity (pregabalin, morphine, amitriptyline). His general practitioner, Dr S., prescribed excessive amounts of multiple med…

general practicepain medicinemedicationcommunicationpregabalin
VICcommunity2021

Finding into death of Mr O

47y · Male·Hanging

A 47-year-old man with newly diagnosed schizophrenia died by hanging. He had presented with paranoid delusions and was engaged with mental health services in February 2017. Critical deficiencies were identified in the me…

psychiatrygeneral practicecommunicationsystemlurasidone
VIC2021

Finding into death of Thi Minh Phuong Nguyen

29y · Female·Mixed drug toxicity (gamma hydroxybutyrate, methylamphetamine, amphetamine, diaz…

A 29-year-old woman with a history of childhood and intimate partner violence died from mixed drug toxicity (GHB, methylamphetamine, amphetamine, diazepam). She had multiple mental health diagnoses including PTSD, depres…

general practicepsychiatrycommunicationsystemgamma hydroxybutyrate
VIChospital2020-12-31

Finding into death of Catherin D'Rozario

17y · Female·Complications of acute asthma in the setting of an allergic response

Catherin D'Rozario, 17 years old, died from complications of acute asthma triggered by anaphylaxis after consuming food containing sesame at a restaurant on 25 August 2019. Despite known allergies to nuts, sesame, fish a…

general practiceemergency medicinediagnosticsystem
WA2020-12-30

Inquest into the Death of Dennis Michael GREEN

Male·multiple injuries sustained in motorcycle crash

Dennis Green, a First Class Constable with WA Police, died on 7 December 2017 while undertaking a motorcycle training course on Julimar Road, Toodyay. His motorcycle crashed on a rural bend during a P1 (high-speed) devel…

diagnosticdelay
VIChome2020-12-30

Finding into death of Brett Jeffrey McDonnell

35y · Male·Hanging

Brett McDonnell, a 36-year-old man, died by hanging in January 2018 while subject to a Community Corrections Order and facing pending criminal charges. He had a history of depression treated with Pristiq since 2015, but …

general practicepsychiatrydiagnosticcommunicationdesvenlafaxine

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