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WAhospital2011-05-12

Inquest into the Death of Walden

68y · Female·Multi-organ failure associated with septic shock following duodenal perforation …

Athenia Hana Walden, 68, died from multi-organ failure and septic shock following duodenal perforation during laparoscopic surgery at Swan District Hospital on 8 May 2008. Surgery was performed to remove her gallbladder,…

general surgerygeneral practicediagnosticcommunicationpethidine
VIChospital2011-05-04

Finding into death of Ms P

30y · Female·Multi organ failure from hydrochloric acid ingestion

Ms P, a 30-year-old woman with recent-onset depression and anxiety, died from multi-organ failure following intentional hydrochloric acid ingestion on 22 September 2008. She had presented to mental health services on 18 …

psychiatrygeneral practicecommunicationsystemtemazepam
WAmental health2011-04-21

Inquest into the Death of Barnes

50y · Female·acute heart failure in association with acute on chronic obstructive airways dis…

Donna Lillian Barnes, a 50-year-old woman with chronic schizophrenia and multiple physical comorbidities including morbid obesity, asthma, and poor mobility, died of acute heart failure associated with acute-on-chronic o…

psychiatrygeneral medicinecommunicationsystemantibiotics
WAhome2011-04-21

Inquest into the Death of Whitehouse

3y · Male·unascertainable; malnourishment was a significant contributing factor

Bradley Frederick Whitehouse, aged 3 months, died on 10 February 2008 from causes ruled unascertainable. He was severely malnourished and emaciated at death, having deteriorated dramatically over the final month of life.…

paediatricsgeneral practicecommunicationdelaymethamphetamine
VICaged care2011-04-14

Finding into death of Anderina Laura Sanderson

89y · Female·Ischaemic heart disease in a woman with a history of recent assault

Mrs Anderina Sanderson, 89, died from ischaemic heart disease four days after being assaulted by a male resident with dementia in an aged care facility. The forensic pathologist concluded the assault accelerated her decl…

geriatric medicinepsychiatrysystemcommunicationparacetamol/codeine
NTcommunity2011-04-08

Inquest into the death of Kieffen Owen Raggett

8y · Male·undetermined

An 8-year-old boy disappeared from Borroloola on 2 October 2007 and was found deceased in a waterhole 2 days later. While initially classified as accidental drowning, the coroner found substantial evidence suggesting fou…

forensic medicinediagnosticsystem
SAhome2011-04-07

Coroner's Finding: LEE Troy Thomas and MATTHEWS Scott Leslie

Troy Thomas Lee: acute neck compression due to hanging; Scott Leslie Matthews: m…

Two men died by suicide while on home detention bail awaiting trial. Troy Thomas Lee (38, hanging) and Scott Leslie Matthews (23, mixed drug toxicity from tramadol and alprazolam overdose) both died on their parents' pre…

general practicepsychiatrycommunicationdelaytramadol
SAhospital2011-04-07

Coroner's Finding: WATKINS Maureen

56y · Female·pulmonary thromboembolism due to left calf deep vein thrombosis

A 56-year-old woman with bipolar disorder died from pulmonary thromboembolism due to left calf deep vein thrombosis while detained under the Mental Health Act in hospital. She presented with seizures and underwent wrist …

general medicinepsychiatrydiagnosticcommunicationdiazepam
QLDhospital2011-04-05

Hoy, Samara Lee

0y · Female·Birth asphyxia due to tight umbilical cord around neck with meconium aspiration

Samara Lea Hoy died shortly after birth from asphyxia caused by a tight umbilical cord around her neck, complicated by meconium aspiration. The coroner identified multiple systemic failures in care. Crucially, admission …

obstetricsmidwiferydiagnosticcommunication
SAhospital2011-03-28

Coroner's Finding: ALLAN Vera

81y · Female·Severe cardiogenic shock complicating cardiac surgery

An 81-year-old woman died of severe cardiogenic shock following elective aortic valve replacement complicated by intraoperative haemodynamic instability and inadequate postoperative ICU management. The surgery involved e…

cardiothoracic surgeryanaesthesiamedicationcommunicationadrenaline
SAaged care2011-03-18

Coroner's Finding: HEATH Dawn Patricia

78y · Female·Severe burns sustained while smoking

A 78-year-old woman with dementia and significant manual dexterity deficits suffered fatal burns while smoking unsupervised in an aged care facility. Despite documented cognitive impairment and physical limitations preve…

systemcommunication
VICcommunity2011-03-17

Finding into death of Stuart Judd

39y · Male·Ischaemic heart disease with complete occlusion of the left anterior descending …

Stuart Judd, a 39-year-old Parks Victoria Ranger, died of acute myocardial infarction due to left anterior descending coronary artery occlusion with ruptured plaque. Eight days before death, he presented to GP Dr V. with…

general practicecardiologydiagnosticdelayomeprazole
NSWhospital2011-03-04

Williammackenzie 2011 03 04 12 58 08 816

60y · Male·Multiple injuries sustained after jumping from 15th storey home unit

William MacKenzie, a 60-year-old with a five-year history of bipolar affective disorder and recent involuntary hospitalization, presented to St. Vincent's Hospital on 9 June 2008 with suicidal ideation after being found …

psychiatryemergency medicinediagnosticproceduralolanzapine
WAcommunity2011-02-28

Inquest into the Death of Collins

0y · Male·cardiac arrhythmia associated with surgically corrected congenital heart disease

Edward Thomas Collins was a 3-month-old neonate with surgically corrected congenital heart disease (Total Anomalous Pulmonary Venous Drainage) who died on 14 January 2007 from cardiac arrhythmia. On 13 January 2007, he p…

emergency medicinegeneral practicediagnosticcommunication
VIChospital2011-02-25

Finding into death of Michael Peysack

69y · Male·Head injury post-collapse secondary to ventricular tachycardia due to ischaemic …

Mr Peysack, a 69-year-old with complex cardiac disease on Warfarin, collapsed at work with witnessed loss of consciousness and occipital laceration. Despite meeting criteria for urgent head CT imaging (age >65, head inju…

emergency medicinecardiologydiagnosticcommunicationwarfarin
NThome2011-02-04

Inquest into the death of Emma Jane Claridge

19y · Female·neck compression due to hanging

Emma Jane Claridge, 19, died by hanging at her home on 26 September 2009, nine hours after being granted day leave from the Cowdy Ward psychiatric ward where she was a voluntary patient. She had been admitted following a…

psychiatrycommunicationsystemrisperidone
VIChospital2011

Finding into death of PB

40y · Male·carbon monoxide poisoning

A 40-year-old male sex offender on community-based orders died by carbon monoxide poisoning on 24 August 2009, two days after a serious suicide attempt involving his car. He had been assessed at Frankston Hospital ED on …

emergency medicinepsychiatrydiagnosticcommunication
VICaged care2011

Finding into death of Mr CR

43y · Male·hypoxic brain injury secondary to asphyxiation by ligature

A 43-year-old man died from hypoxic brain injury due to asphyxiation by ligature while an inpatient at a rehabilitation centre. He had undergone spinal surgery for back pain and cauda equina syndrome but was failing to i…

neurosurgeryrehabilitation medicinecommunicationsystem
VIChospital2011

Finding into death of ALYSSA TZE SIM CHAN

Female·Combination of liver failure, blood loss and shock following needle biopsy

Alyssa, a 9-week-old infant, died from hemorrhage following a liver biopsy at Monash Medical Centre. She had persistent jaundice, and biopsy was undertaken to investigate potential biliary atresia. Post-operatively, nurs…

gastroenterologyanaesthesiadiagnosticproceduralphytomenadione
VIC["community", "home"]["2010-03-03", "2010-02-25"]

Finding into death of Bayden Roy Smith

[47, 77]y · ["male", "female"]·["gunshot injury to head (self-inflicted)", "neck compression"]

Two coronial findings are provided. First, Bayden Roy Smith, 47, died by self-inflicted gunshot wound hours after crisis mental health assessment at Broadmeadows Police Station. The CAT team assessed him as low-risk and …

psychiatryemergency medicinediagnosticcommunication

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