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VIC2020-05-05

Finding into death of Richard Neil Gaudion

60y · Male·Injuries sustained in a motor vehicle incident (driver)

Richard Gaudion, a 60-year-old Wild Dog Controller, died when his 4WD vehicle rolled down a steep embankment in remote bushland. WorkSafe identified seven contributing factors: outdated 4WD training (last completed in 20…

occupational and environmental healthforensic medicinesystemdelay
VIChospital2020-05-05

Finding into death of John Hayle

76y · Male·Bronchopneumonia in a man with ischaemic heart disease and treated spinal crush …

John Hayle, a 76-year-old with Alzheimer's dementia, ischaemic heart disease, and spinal fractures sustained a T11/12 flexion-distraction fracture on 9 June 2017. Over three weeks, he developed progressive bilateral lowe…

neurosurgerygeriatric medicinediagnosticcommunicationmk8931
WAhospital2020-04-24

Inquest into the Death of Hassan BECHARA

52y · Male·ischaemic heart disease

Hassan Bechara, a 52-year-old prisoner, died from ischaemic heart disease in July 2017. He had complex cardiac history including dilated cardiomyopathy, triple-vessel coronary disease, and previous cardiac procedures. Cl…

cardiologyemergency medicinedelaysystematorvastatin
VIChospital2020-04-23

Finding into death of John Alexander King

60y · Male·Mixed drug toxicity

A 60-year-old man with schizophrenia and depression presented to Maroondah Hospital ED with acute psychotic symptoms after stopping his antipsychotic medication (trifluoperazine) due to manufacturer discontinuation. He w…

emergency medicinepsychiatrysystemcommunicationtrifluoperazine
VICaged care2020-04-22

Finding into death of Dorothy May Nelson

81y · Female·Complications of choking on a food bolus in a woman with dementia

Dorothy May Nelson, an 81-year-old woman with dementia, died from complications of choking on a food bolus at an aged care facility. She was served diced beef in casserole (approximately 4cm bolus found at autopsy, despi…

geriatric medicinepsychiatrydiagnosticproceduralmorphine
QLDcommunity2020-04-17

Russo, Matthew Anthony

37y · Male·Cardiac failure due to sepsis due to bilateral bronchopneumonia

Matthew Russo, a 37-year-old man, died from sepsis and cardiac failure secondary to bilateral bronchopneumonia within 18 hours of consultation with Dr M.. The coroner found the medical treatment inadequate and inappropri…

general practicerespiratory medicinediagnosticcommunicationamoxicillin
TAS2020-04-15

Coroner's Finding: Southwell, Sandra

Female·multiple traumatic injuries sustained in aircraft crash

Sandra Southwell died from multiple traumatic injuries sustained in a Cessna 182P aircraft crash at Tomahawk, Tasmania. The pilot attempted to land with a tailwind after failing to identify the prevailing easterly wind d…

system
TASaged care2020-04-08

Coroner's Finding: Emery, Judith Anne

74y · Female·Chest and abdominal injuries from fall from cliff; possible terminal drowning

Judith Anne Emery, aged 74, died from chest and abdominal injuries sustained in a fall from a cliff near her retirement village, with possible terminal drowning. She was last seen on 24 September 2016 delivering a meal t…

systemcommunication
VIChome2020-04-07

Finding into death of Jesse Stephen Bird

32y · Male·neck compression in the circumstances of hanging

Jesse Bird, a 32-year-old Torres Strait Islander veteran, died by suicide in June 2017 after struggling to navigate the Department of Veterans' Affairs (DVA) compensation system. He served in Afghanistan in 2009, develop…

psychiatryparamedicinesystemcommunicationduloxetine
VIC2020-04-06

Finding into death of Darren Brandon

51y · Male·hypoxic-ischemic encephalopathy due to hanging

Darren Brandon died by hanging in prison on 10 June 2018, two days after arriving at Melbourne Assessment Prison. He was a 51-year-old man with acquired brain injury from a 2003 motorcycle accident, depression, and histo…

psychiatryforensic medicinecommunicationsystemoxycodone
VIC2020-04-06

Finding into death of Robert James Lawerence

29y · Male·Shotgun wound to the head

Robert James Lawrence, a 29-year-old man with complex mental health needs including ADHD, depression, anxiety, Tourette's syndrome, and borderline personality traits, died from a self-inflicted shotgun wound. He held a C…

psychiatrypsychologycommunicationsystem
WAhospital2020-04-02

Inquest into the Death of Valerie KELLY

67y · Female·bronchopneumonia and acute liver failure on a background of liver cirrhosis and …

Valerie Kelly, a 67-year-old woman with cirrhosis, hepatocellular carcinoma, and multiple comorbidities, died at Royal Perth Hospital from bronchopneumonia and acute liver failure. She was in custody at Bandyup Women's P…

hepatologygastroenterologycommunicationsystemolanzapine
TASaged care2020-04-01

Coroner's Finding: Standaloft, Cora Gwendoline

94y · Female·pneumonia due to traumatic left rib fractures, complicated by malignant left ple…

Mrs Standaloft, aged 94, died of pneumonia due to traumatic left rib fractures complicated by malignant pleural effusion and recurrent lung carcinoma, sustained in an unwitnessed fall at a nursing home on 31 December 201…

geriatric medicinepalliative caresystem
QLDhome2020-03-30

Hinder, Nyobi Jade; Hinder, River James & Hinder, Charlie

7y · Female·Explosion caused intentionally by Charlie Hinder; children died instantly from b…

Three deaths resulted from an intentional explosion caused by Charlie Hinder in a caravan containing himself and his two children (ages 4 and 7) during marital separation. Charlie had perpetrated coercive controlling dom…

communicationsystem
VIChospital2020-03-26

Finding into death of Matthew John George

45y · Male·Global cerebral hypoxia following cardio-respiratory collapse due to anaphylaxis…

A 45-year-old man with poorly controlled diabetes, ischaemic heart disease, and recurrent lower limb infections died from anaphylaxis to intravenously administered flucloxacillin. He presented with sepsis secondary to a …

general medicineinfectious diseasescommunicationdiagnosticflucloxacillin
NSWcommunity2020-03-25

Inquest into the death of Tory GANDERTON

3y · Male·respiratory failure, with spinal muscular atrophy an antecedent cause

Tory Ganderton, a 3-year-old boy with spinal muscular atrophy (SMA) Type 1, died of respiratory failure during inter-hospital transfer. Admitted to Shoalhaven Hospital on 7 September 2014 with pneumonia and severe malnut…

paediatricsneurologycommunicationsystemadrenaline
NSW2020-03-25

Inquest into the death of Mahmoud ALLAM

28y · Male·MRSA sepsis

Mahmoud Allam, a 28-year-old man, died from MRSA sepsis whilst in custody at Parklea Correctional Centre. He initially presented with upper respiratory symptoms on 11 June 2016, followed by increasing symptoms including …

infectious diseasesemergency medicinecommunicationsystemflucloxacillin
TAShome2020-03-23

Coroner's Finding: Szemes, Kim Leonie Maree

59y · Female·Unable to determine - body too decomposed at autopsy

Mrs Szemes, a 59-year-old woman with longstanding mental health issues living alone, was found deceased after an interval of approximately 5 months. On 28 May 2018, police attended her home after welfare concerns and cal…

paramedicinepsychiatrycommunicationsystem
WAhospital2020-03-20

Inquest into the Death of Norman Alexander HAZELGROVE

73y · Male·metastatic carcinoma of the lung with palliation

Norman Hazelgrove, a 73-year-old prisoner, died from metastatic lung carcinoma in September 2017. Early in his imprisonment (2013), a chest X-ray showed COPD but this diagnosis was not formally documented or managed desp…

respiratory medicineoncologydiagnosticsystemantihypertensive medication
VIChome2020-03-20

Finding into death of Janet Foster

55y · Female·Mixed drug toxicity in a woman with cardiomegaly and chronic obstructive airway …

Janet Foster, 55, died from mixed drug toxicity involving heroin/morphine combined with benzodiazepines in the context of cardiomegaly and chronic obstructive airway disease. She was a voluntary palliative care patient a…

emergency medicinegeneral practicecommunicationsystemmorphine

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