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WAcommunity2020-08-18

Inquest into the Death of Jessica Lesley JACKSON

18y · Female·multi-organ failure due to combined effects of environmental exposure (hyperther…

Jessica Jackson, 18, died from multi-organ failure due to combined hyperthermia and dehydration while weight-cutting for an amateur Muay Thai fight. She lost approximately 9 kg in the final week through water-loading, de…

emergency medicinesports medicinediagnosticsystem
VIChome2020-08-17

Finding into death of Benjamin James Browne

29y · Male·Incised injury to the neck

Benjamin Browne, 29, died from a neck laceration sustained during acute behavioural disturbance in August 2018. He had diagnosed major depression with anxiety, prescribed mirtazapine but attended only two psychology sess…

general practicepsychologysystemcommunicationmirtazapine
WAhospital2020-08-13

Inquest into the Death of Susan Jessica Elsie WINDIE

22y · Female·bowel obstruction due to faecal impaction

Susan Windie, a 22-year-old with rare congenital abnormalities affecting bowel function, died from bowel obstruction due to faecal impaction complicated by abdominal compartment syndrome. She presented to Carnarvon Hospi…

gastroenterologygeneral practicecommunicationsystemfleet enema
TAShome2020-08-13

Coroner's Finding: Wellington, Timothy John

44y · Male·intravenous injection of foreign debris (crushed tablets) associated with chroni…

Timothy Wellington, a 44-year-old man with longstanding opioid and polysubstance use disorder, died from acute pulmonary hypertension caused by intravenous injection of foreign debris (crushed tablets). He had been presc…

general practiceaddiction medicinemedicationsystemmethadone
VIChome2020-08-11

Finding into death of Angel Louise Hensgen

13y · Female·Acute paracetamol toxicity

Angel Hensgen, aged 13, died from acute paracetamol toxicity following intentional self-harm with an excessive overdose. She was exposed to intense cyberbullying, distressed by family relationships, peer conflicts, and a…

general practicetoxicologycommunicationsystemparacetamol
NSWhome2020-08-11

Inquest into the death of A

74y · Male·gunshot wound to the head

A 74-year-old man died from a self-inflicted gunshot wound to the head during a police response to a domestic violence call. Officers were dispatched following his assault on his wife, who was injured. The primary clinic…

communicationsystemalcohol
TAS2020-08-10

Coroner's Finding: Williamson, Colin George

72y · Male·Severe head and chest trauma sustained in a tree-felling accident; multiple seve…

Colin Williamson, aged 72, died from severe head and chest trauma sustained during a tree-felling accident on his friend's property. He was struck by a falling tree branch while operating a log splitter. Critical failure…

proceduralsystem
TAScommunity2020-08-07

Coroner's Finding: Delios, Voula 2020 TASCD 458

63y · Female·Multiple stab wounds to neck and chest

Voula Delios, a 63-year-old grocer in Hobart, was fatally stabbed by Daryl Cook on 23 July 2016, one day after his release from prison. Cook suffered from serious untreated mental illness, evidenced by extensive prison r…

psychiatrycorrectional healthdiagnosticsystemolanzapine
WAmental health2020-08-06

Inquest into the Death of Stephen Michael KELL

35y · Male·acute vomit aspiration in a man with acute large intestine obstruction (severe m…

Stephen Michael Kell, a 35-year-old man with treatment-resistant schizophrenia, died at Graylands Hospital from acute vomit aspiration in the setting of acute large bowel obstruction and clozapine-induced gastrointestina…

psychiatrygastroenterologysystemdelayclozapine
WAcommunity2020-08-04

Inquest into the Death of Shirley June FINN

34y · Female·multiple gunshot wounds to the head

Shirley Finn, a 34-year-old Perth brothel owner, was murdered on 22 June 1975, shot four times in the head in her car near Royal Perth Golf Club. The Deputy State Coroner found cause of death was multiple gunshot wounds …

forensic medicinesystemcommunication
VIChospital2020-07-31

Finding into death of Julie-Ann Margaret Johnston

61y · Female·Injuries sustained in a motor vehicle collision (pedestrian)

A 61-year-old woman was struck by a bus at Croydon Railway Station while crossing a pedestrian zebra crossing. She sustained severe injuries and went into cardiac arrest upon arrival at Royal Melbourne Hospital, where sh…

emergency medicinetrauma surgerysystem
VICmental health2020-07-30

Finding into death of William Thomas Flanagan

57y · Male·Multiple injuries sustained by being struck by a freight train

A 57-year-old man with 28-year history of treatment-resistant schizophrenia died by suicide when he absconded from an acute psychiatric unit and stepped in front of a train. Despite comprehensive psychiatric management i…

psychiatrycardiologysystemvenlafaxine
NSWaged care2020-07-29

Inquest into the death of John Pocklington

31y · Male·Acute Myocardial Infarction

John Pocklington, aged 31, died of acute myocardial infarction while in remand custody. He had a long history of methamphetamine use and untreated cardiac damage. On 28 April 2015, he reported chest pain to a nurse, who …

cardiologypsychiatrydiagnosticcommunicationmethamphetamine
VICaged care2020-07-22

Finding into death of Dorothy Boyle

92y · Female·Complications of a fractured left femur (operated), sustained in a fall

Dorothy Lorraine Boyle, aged 92, died from complications of a left femoral fracture sustained in a fall at an aged care facility. She fell while attempting to push out a wandering dementia-affected resident who had enter…

geriatric medicineemergency medicinesystemprocedural
TAScommunity2020-07-17

Coroner's Finding: Lyons, Matthew Clayton

47y · Male·mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam and diazepam)

Matthew Clayton Lyons, a 47-year-old man with longstanding schizophrenia, severe anxiety, and substance abuse history, died from mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam, diazepam). He had expre…

psychiatrygeneral practicecommunicationsystemquetiapine
WAhome2020-07-16

Inquest into the Death of CHILD RM

17y · Female·ligature compression of the neck (hanging)

A 17-year-old girl in state care died by suicide on 16 April 2017 after being discharged from secure care. She had experienced complex developmental trauma, family violence, sexual abuse, and severe alcohol-related liver…

paediatricspsychiatrysystemcommunicationalcohol
VIChospital2020-07-16

Finding into death of Lydia Maxfield

85y · Female·Multisystem failure complicating ischaemic heart disease and ischaemic bowel in …

Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnorm…

orthopaedic surgeryanaesthesiacommunicationsystemondansetron
VIChospital2020-07-14

Finding into death of Gerard Guy Vaz

61y · Male·Undetermined

Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuc…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
VICcommunity2020-07-13

Finding into death of Cameron Andrew MacLellan

44y · Male·Multiple injuries sustained in a motorcycle incident

A 44-year-old man with complex psychiatric history and substance abuse was killed in a motorcycle collision while driving unlicensed and under the influence of methylamphetamine. A 92-year-old driver, disoriented after b…

psychiatryaddiction medicinesystemdelaymethamphetamine
VICaged care2020-07-06

Finding into death of Irene Florence Curran

79y · Female·Ischaemic bowel in the setting of cardiomegaly, pneumonia and chronic renal fail…

A 79-year-old woman died from ischaemic bowel in the setting of cardiomegaly, pneumonia and chronic renal failure, four days after discharge from hospital following a hysterectomy for endometrial cancer. Key clinical les…

gynaecologygeneral practicecommunicationsystemoxycodone

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