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NTcommunity2010-03-30

Inquest into the death of Michael Anthony Hardy and Robert James Roe

Unknown·Michael Anthony Hardy: acute asphyxiation sustained during dog pack attack. Robe…

Two deaths occurred at Hidden Valley Camp in Alice Springs within weeks of each other. Michael Hardy, aged 27, died from asphyxiation during a dog pack attack while severely intoxicated. Robert Roe, aged 47, died from co…

public healthoccupational and environmental healthsystemcommunicationalcohol
QLDcommunity2010-03-25

Howlett, Peter David

44y · Male·acute myocardial ischaemia due to coronary artery occlusion due to thrombosis an…

Peter Howlett, a 44-year-old male, died of acute myocardial infarction on 21 April 2006 after a 54-minute delay in ambulance arrival. His wife called Triple 0 reporting back pain radiating to chest at 7:20 am. Critical c…

emergency medicineparamedicinecommunicationdiagnostic
VIChospital2010-03-24

Finding into death of Adam Michael Francis Fabre

19y · Male·acute bacterial meningitis with secondary cerebritis (meningococcus)

Adam Fabre, a 19-year-old with fever, severe headache, neck pain, muscle pain (10/10), vomiting, tachycardia and blanching rash, presented to Casey Hospital ED at 3:45am on 14 July 2006. Despite expressing clear concern …

emergency medicineinfectious diseasesdiagnosticcommunicationparacetamol/codeine
VIChospital2010-03-24

Coroner's Finding: Janet Carol Rosse

32y · Female·Mexiletine toxicity

Janet Rosse was a 32-year-old woman with hyperkalaemic periodic paralysis, a genetic neurological condition causing recurring paralytic episodes and chronic pain, and a concurrent history of major depression and anxiety.…

neurologypsychiatrycommunicationsystemmexiletine
QLDhome2010-03-05

Child at Mackay

15y · Female·Ligature compression of the neck (hanging)

A 15-year-old Aboriginal girl died by suicide by hanging on 29 November 2007. She had a transient lifestyle with unstable housing, moved frequently between relatives, was not regularly attending school, and engaged in su…

paediatricspsychiatrysystemdelayalcohol
WAhospital2010-03-03

Inquest into the Death of McLevie

38y · Female·Streptococcus Group A Septicaemia (Post Partum-Puerperal Sepsis)

Susannah McLevie, a 38-year-old woman, died on 6 April 2006 from untreated Group A Streptococcal septicaemia (puerperal sepsis) following childbirth at Osborne Park Hospital. She developed fever (38°C) at 3am on 5 April,…

obstetricsmidwiferydiagnosticcommunicationparacetamol/codeine
VIC2010-02-08

Finding into death of Craig Walter Stevens

34y · Male·Hypoxic-ischaemic brain injury caused by hanging

Craig Stevens, aged 34, died from hypoxic-ischaemic brain injury following a suicide by hanging on 17 June 2008. Despite police intervention, critical delays in cutting the ligature around his neck prevented timely resus…

psychiatrygeneral practicesystemdelaysertraline
SAhospital2010-02-04

Coroner's Finding: KRIVITCH Olga

81y · Female·hypovolaemic shock following bleeding from the site of a femoral angiogram

Olga Krivitch, 81-year-old woman, died from hypovolaemic shock caused by bleeding from her femoral angiogram puncture site. She was admitted for ischaemic leg and underwent unsuccessful thrombolytic therapy. Subsequently…

vascular surgeryradiologydiagnosticmedicationheparin
WAhospital2010-02-04

Inquest into the Death of Hudson

20y · Male·Ligature compression of the neck (hanging)

Allan Kevin Hudson, a 20-year-old male with a history of depression, suicidality, substance abuse and previous sexual trauma, died by hanging on 13 August 2006 at Sir Charles Gairdner Hospital's psychiatric ward D20. He …

psychiatryemergency medicinediagnosticcommunicationcarbamazepine
VICcommunity2010-01-20

Finding into death of Jennifer Gibbins

54y · Female·Sepsis due to bronchopneumonia complicating malignant spindle cell tumour of rig…

Jennifer Gibbins, a 54-year-old woman with non-verbal communication disability living in supported accommodation, presented with recurrent cough from April 2005. Initial management consisted of antibiotics prescribed by …

general practicerespiratory medicinediagnosticdelayantibiotics
NTcommunity2010-01-19

Inquest into the death of Baby Kalib (Child 7)

0y · Male·failure to thrive due to insufficient caloric intake

Kalib died from failure to thrive due to insufficient caloric intake at 7 weeks old. He was born to a mother with a documented history of severe neglect and physical abuse of multiple children over 5 years, during which …

paediatricsgeneral practicesystemcommunication
NThome2010-01-19

Inquest into the death of Deborah Leanne Melville

12y · Female·acute septicaemia resulting from osteomyelitis of the left femur

A 12-year-old Aboriginal girl died from septicaemia caused by untreated osteomyelitis of the left femur. Three weeks after a sports injury, despite evidence of severe and deteriorating illness including inability to walk…

orthopaedic surgeryinfectious diseasesdiagnosticsystem
VIC2010-01-14

Finding into death of Sharkia Handy

14y · Female·hanging

Sharkia Handy, a 14-year-old girl in out-of-home care, died by hanging in December 2007. She had significant unaddressed mental health concerns including suicidal ideation, self-harm, and grief following peer suicides. T…

paediatricspsychiatrycommunicationsystem
VIChospital2010

Finding into death of Nicole Joy Millar

42y · Female·Complications of cutaneous burns

Nicole Joy Millar, 42, died from severe burns inflicted by her intimate partner in a premeditated attack at a petrol station. She had disclosed prior intimate partner violence to support services but remained isolated an…

emergency medicineplastic and reconstructive surgerycommunicationsystemdiazepam
VICcommunity2010

Finding into death of Mikael Chandra Rohan

14y · Male·head injuries when struck by a train

Mikael Rohan, a 14-year-old with a history of separation anxiety, attachment disorder, and sleep disturbance, died after stepping in front of a train on 16 November 2010. He had recently been distressed about a reported …

psychiatrygeneral practicediagnosticcommunicationtemazepam
SAhospital2009-12-31

Coroner's Finding: LYNN Matthew John

20y · Male·hypoxic encephalopathy

Matthew Lynn, aged 20, died from hypoxic encephalopathy after sustaining head injuries in a motor vehicle collision. While hospitalised in ICU, his endotracheal tube (ETT) became displaced around 12:20am on 23 January 20…

intensive careanaesthesiadiagnosticcommunicationpropofol
VIC2009-12-22

Finding into death of Andrew Phillip Mull

34y · Male·Multiple injuries sustained in helicopter crash caused by tail rotor failure

Andrew Mull, a 34-year-old builder and pilot, died when his homebuilt Rotorway Exec 162 helicopter crashed on 29 March 2006 near Mount Beauty, Victoria. The coroner found tail rotor failure was the likely cause of the cr…

aviation medicinesystemdiagnostic
QLDhospital2009-12-16

Davidson, Yvonne Alice

75y · Female·Septicaemia as a result of lobar pneumonia; congestive heart failure also presen…

A 75-year-old woman died from septicaemia following a percutaneous tracheostomy procedure performed by a locum consultant on a Sunday. The procedure deviated significantly from the established ICU protocol: it was perfor…

intensive careanaesthesiaproceduralcommunication
SAmental health2009-12-04

Coroner's Finding: BLUNDEN Peter Ross

54y · Male·hanging by ligature

Peter Ross Blunden, a 54-year-old man with chronic schizophrenia detained under the Mental Health Act, died by hanging in the shower room of Cramond Clinic open ward. He had expressed suicidal ideation throughout his adm…

psychiatryemergency medicinecommunicationsystemoxazepam
NThospital2009-12-02

Inquest into the death of Matthew Winsloe Hinton

18y · Male·acute multiple drug toxicity

Matthew Hinton, an 18-year-old male, died from acute multiple drug toxicity after consuming nine LSD tablets and methamphetamine. Police attended at approximately 5:30am when called to a disturbance, but a critical delay…

emergency medicineintensive carecommunicationsystemLSD

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