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NTcommunity2007-11-12

Inquest into the death of Angel Blanco-Puerto, Phillip Lindsay, Barry Gaykamangu and Hannu Kononen

Male·Angel Blanco-Puerto: acute heart failure as result of long-standing damage from …

Four men died from acute heart failure after ambulance officers declined or inadequately pursued hospital transport. In Angel Blanco-Puerto, no potentially life-threatening condition was identified at the time. However, …

emergency medicinecardiologydiagnosticcommunication
SAhome2007-11-09

Coroner's Finding: RANDALL Treenor Heather

50y · Female·mixed tablet overdosage (quetiapine and venlafaxine with codeine)

Treenor Heather Randall, a 50-year-old registered nurse, died from mixed tablet overdose (quetiapine and venlafaxine) following a progressive mental health decline. After work-related stress in late 2002, she developed d…

general practicepsychiatrycommunicationdelayquetiapine
QLDhospital2007-11-06

Huber, Arisa

1y · Female·sudden unexpected death in infancy due to hypoxic episode while co-bedding with …

Arisa Huber, a newborn, died from sudden unexpected death in infancy (SUDI) due to hypoxic episode while co-bedding with her exhausted mother in a postnatal ward. The infant was found without breathing or pulse at 6:45am…

neonatologyobstetricscommunicationsystem
QLDhospital2007-10-29

Cvitic, Nardia Annett

30y · Female·Multi-organ failure due to multiple transfusions required for post-operative ble…

Ms Cvitic, a 30-year-old woman with cervical cancer, underwent radical hysterectomy on 11 February 2002. She collapsed on 14 February with signs of hypovolaemic shock (haemoglobin 5.3 g/dL). Dr W. performed emergency lap…

oncologygeneral surgerydiagnosticmedicationheparin
QLDhospital2007-10-01

Fogarty, Kevin Edward

37y · Male·Community acquired pneumonia as a result of melioidosis infection

Kevin Fogarty, a 37-year-old power lineman, died from melioidosis-related community-acquired pneumonia at Winton Hospital after a 4-day admission. He likely contracted melioidosis through occupational exposure to mud dur…

general practiceemergency medicinediagnosticcommunicationdiazepam
SAhospital2007-09-18

Coroner's Finding: MARKANTONAKIS Stefanos

63y · Male·uncontrolled haemorrhage from ruptured aortic aneurysm

A 63-year-old man presented with sudden back pain on 6 March 2004. Ambulance officers attended twice; on the first visit they did not transport him to hospital despite his request, misattributing his symptoms to musculos…

emergency medicineparamedicinediagnosticcommunicationparacetamol/codeine
WAhome2007-09-14

Inquest into the Death of Jones Coronial

9y · Male·Head injury (epidural haematoma with cerebral coning following craniotomy)

Dwayne Michael Jones, aged 9, had Trisomy 10, a rare congenital chromosomal disorder causing severe developmental delay and neurological abnormalities. On 11 April 2000, he fell from a computer desk and struck his head. …

general practiceemergency medicinediagnosticdelayparacetamol
QLDhospital2007-09-03

Henderson, Robert Joseph

31y · Male·mixed drug toxicity

Robert Henderson, 31, died from mixed drug toxicity while subject to a community involuntary treatment order for schizophrenia. He was admitted to hospital on 9 July 2005 after his case manager appropriately identified e…

psychiatryemergency medicinediagnosticdelaymorphine
QLDhospital2007-08-17

Mental Health patient

71y · Male·hypoxic brain injury due to hanging

A 71-year-old farmer with a 10-year history of major depressive disorder with melancholic features died by hanging on 22 July 2005, three days after admission to a private psychiatric hospital (Belmont) following a medic…

psychiatryemergency medicinecommunicationdiagnostictemazepam
QLDhome2007-08-10

Stiller-Smith, Felix Jake

0y · Male·undetermined; possible drug effect, hypoxia, or asphyxia; methylamphetamine expo…

Felix Jake Stiller-Smith, a 37-day-old infant, died on 6 February 2003 while co-sleeping with his mother. The cause of death remained undetermined at autopsy, though heavy, congested internal organs suggested possible dr…

paediatricspathologycommunicationsystemamphetamine
QLDhospital2007-08-10

Tang, Shannon Sheng Wen

21y · Male·multi-organ failure due to septicaemia of mixed respiratory (bronchopneumonia) a…

Shannon Tang, a 21-year-old from Singapore with severe obesity (BMI 52) and multiple comorbidities including sleep apnoea, underwent elective laparoscopic gastric bypass surgery performed by Dr F.. He died on day 7 post-…

bariatric surgerygeneral surgerycommunicationdiagnosticvancomycin
SAhospital2007-08-02

Coroner's Finding: GILLAM Peter Roy

44y · Male·Sepsis and pulmonary thromboemboli complicating a ruptured cerebral artery aneur…

Peter Gillam, age 44, died from sepsis and pulmonary thromboemboli complicating a ruptured cerebral aneurysm with subarachnoid haemorrhage (SAH). On 16 December 2004, his GP Dr H. referred him urgently for CT head to exc…

emergency medicinegeneral practicediagnosticcommunicationsalbutamol
SAaged care2007-08-02

Coroner's Finding: LESLIE Mona Belle

95y · Female·asphyxia due to glottic obstruction by food

A 95-year-old female with advanced dementia died from asphyxia caused by food impaction in the glottis. She was prescribed a soft diet (soft vegetables, vitamised meat) but was served and fed a meal containing large unco…

geriatric medicinespeech pathologydiagnosticcommunicationcitalopram
WAhome2007-07-27

Inquest into the Death of Chubby

64y · Female·Acute bronchopneumonia in a woman with liver failure

Patsy Chubby, 64, died from acute bronchopneumonia complicated by terminal liver failure and multiple chronic conditions (cardiac cirrhosis, heart failure, COPD, diabetes, pulmonary hypertension). Discharged from hospita…

general medicinecardiologycommunicationdiagnostic
SA2007-07-12

Coroner's Finding: SANSBURY Colin Craig

24y · Male·diffuse hypoxic ischaemic encephalopathy due to hanging

Colin Craig Sansbury, 24-year-old Aboriginal man, died by hanging while in police custody at Elizabeth Police Station. Critical failures in care included: (1) Inadequate psychiatric assessment at Lyell McEwin Hospital—he…

emergency medicinepsychiatrydiagnosticcommunicationdiazepam
SAhospital2007-06-29

Coroner's Finding: COCKBURN Michael Philip

40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)

Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anae…

psychiatryemergency medicinemedicationcommunicationhaloperidol
NThome2007-06-28

Inquest into the death of Monica Presley

7y · Female·electrocution

Monica Presley, a 7-year-old Aboriginal girl, died from electrocution when she contacted a live metal frame of a faulty evaporative air conditioner (EAC) outside her public housing flat in Tennant Creek. The EAC had been…

proceduralsystem
SAcommunity2007-06-08

Coroner's Finding: COOKE Rowan Douglas

37y · Male·dehydration/heat-related death

A 37-year-old man died from dehydration and heat-related illness after collapsing in a sweat lodge during a vision quest ceremony in remote South Australia. He remained unconscious after removal from the lodge, but the g…

emergency medicineintensive carediagnosticdelay
QLDmental health2007-06-01

Huntington, Sparka Isarva aka Huntington, James Philip

31y · Male·Undetermined; most likely coronary atherosclerosis leading to arrhythmia, but as…

Sparka Huntington, a 31-year-old forensic mental health patient with a history of schizophrenia, violence, and drug use, died during physical restraint by hospital security officers and nursing staff on 14 December 2003.…

psychiatryemergency medicinediagnosticmedicationzuclopenthixol
QLDmental health2007-05-25

Mental Health patient

Female·multiple injuries due to a fall from height (suicide by jumping from multi-store…

A woman with major depressive disorder and psychotic features died by suicide at a shopping centre car park on 21 September 2004, six days after admission to Belmont Private Hospital under an involuntary treatment order.…

psychiatryemergency medicinecommunicationsystemmirtazapine

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