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QLD2007-05-16

Davis, Jodie Maree

24y · Female·hypoxic brain damage due to cardiac arrest due to hanging

Jodie Maree Davis, aged 24, died by suicide in Townsville Correctional Centre in May 2002. She had a long history of self-harm dating from age 15, including multiple suicide attempts, and was assessed as high suicide ris…

psychiatrypsychologysystemcommunication
WAcommunity2007-05-11

Inquest into the Death of Robson

16y · Female·Adrenal insufficiency (Addison's Disease)

Emma Louise Robson, a 16-year-old female, died on 29 September 2004 from adrenal insufficiency (Addison's Disease), a treatable autoimmune condition. She presented with progressive fatigue, weight loss (from 48–50 kg to …

general practiceemergency medicinediagnosticsupervision_issue
QLDhospital2007-05-04

Horsington, Margaret Isabel

83y · Female·cardiac arrest from severe triple vessel coronary artery disease complicated by …

Margaret Isabel Horsington, aged 83, died from cardiac arrest secondary to severe coronary artery disease, complicated by large bowel obstruction from rectal carcinoma. She presented to Roma Hospital with constipation an…

general surgeryemergency medicinediagnosticcommunicationfleet
SA2007-04-26

Coroner's Finding: CHRISTOPHER Penelope Rae and TRENORDEN John

53y · Male·asphyxia from combined effects of neck compression from hanging and suffocation …

John Trenorden died by suicide in prison following his arrest for allegedly murdering his former business partner Penelope Christopher. Police correctly identified him as at-risk after he attempted to step in front of tr…

psychiatrygeneral practicecommunicationsystemallopurinol
QLDhospital2007-04-05

Smith, Arthur Lawrence

75y · Male·Acute cardiac failure due to mitral valve disease (surgically treated)

Arthur Lawrence Smith, 75, underwent successful mitral valve repair and coronary artery bypass grafts at TPCH on 2 August 2004 and was discharged 5 days later. On 19 August, his wife called TPCH reporting acute shortness…

cardiothoracic surgeryemergency medicinecommunicationdiagnosticadrenaline
QLD2007-03-30

Pittaway, Steven John and Coe, Paul Allen

Male·Coe: self-inflicted hanging; Pittaway: neck compression due to self-inflicted st…

Two men died by suicide in Bundaberg Watch House within 7 months. Paul Coe (38) hanged himself using his shirt from a door hinge on 11 June 2005, approximately 25 minutes after officers last physically checked him. Steve…

forensic medicinetoxicologysystemcommunicationmethamphetamine
QLDhome2007-03-22

Dee, Fiona Jane

32y · Female·Hypoxic brain injury due to a combination of factors arising from subdural haema…

A 32-year-old fit and healthy woman died from hypoxic brain injury following complications of spinal anaesthesia for caesarean section. She developed a subdural haematoma (rare complication) and persistent post-dural pun…

obstetricsanaesthesiacommunicationdiagnosticcarbamazepine
QLD2007-03-06

Browne, Roger Bruce

41y · Male·injuries sustained when he fell from height into a pit full of water

Roger Bruce Browne, a 41-year-old contract holder at Dawson Mine, died after falling from height into a pit at disused pit 8C. He suffered fatal injuries including cervical spine dislocation and internal injuries; death …

occupational and environmental healthforensic medicinesystemdelay
QLDmental health2007-03-02

Lather, David Andrew

24y · Male·aspiration of gastric contents due to or as a consequence of drug toxicity follo…

Andrew Lather, aged 24, died at Charters Towers Rehabilitation Unit on 6 March 2004 from aspiration of gastric contents due to drug toxicity after ingesting approximately 150 tablets from a medication drawer beside his b…

psychiatryrehabilitation medicinesystemcommunicationquetiapine
QLD2007-03-01

McGeary, Corey Allan

20y · Male·Self-inflicted hanging

Corey McGeary, a 20-year-old remand prisoner with chronic risk factors for self-harm (history of suicide attempts, schizophrenia, personality disorder, severe childhood abuse, mild intellectual disability), died by hangi…

psychiatrypsychologycommunicationsystemolanzapine
SApolice station2007-02-08

Coroner's Finding: CARTWRIGHT Stephen Andrew

51y · Male·Hanging

Stephen Cartwright, a 51-year-old psychologist, was arrested for breach of bail and died by hanging in police custody at Christies Beach Police Station. He displayed multiple risk factors including depression requiring m…

diagnosticcommunicationtemazepam
QLDhome2007-02-06

Marshall, Maxwell John

48y · Male·Undetermined

Maxwell Marshall, aged 48, died in December 2003 from undetermined causes after receiving escalating doses of oxycodone (Oxycontin) for post-Guillain-Barré neuropathic pain reaching 680mg daily—among the highest 1% of pr…

general practicepain medicinediagnosticcommunicationoxycodone
SA2007-01-30

Coroner's Finding: CHALKLEN Stuart Murray

38y · Male·ischaemic heart disease due to severe coronary atherosclerosis

Stuart Murray Chalklen, aged 38, died in Adelaide Remand Centre from ischaemic heart disease due to severe coronary atherosclerosis. He complained of left shoulder pain (a recognised symptom of cardiac disease) to cellma…

cardiologyemergency medicinediagnosticsystem
QLD2007-01-19

Carroll, Leon Mark

Male·Self-inflicted hanging

Leon Mark Carroll died by hanging in prison while on remand for sexual offences. Initial assessment identified significant suicide risk, but this was reversed by the High Risk Assessment Team after only 5-6 minutes consi…

psychiatrypsychologydiagnosticsystemdiazepam
QLDhospital2007-01-10

West, Ian Leslie

26y · Male·bronchopneumonia following severe head injury

Ian Leslie West, a 26-year-old man with bipolar affective disorder, died from bronchopneumonia following severe head injury sustained when he fell from a hospital balcony on 31 December 2002. He had been admitted to Long…

psychiatryemergency medicinemedicationcommunicationacuphase
SAhospital2007-01-03

Coroner's Finding: FOOT Brodie Sian

23y · Female·drowning and citalopram overdose

23-year-old woman with major depressive disorder presented to multiple healthcare providers on 17 March 2004 with suicidal ideation. She was referred to Flinders Medical Centre Emergency Department by her GP, where she w…

general practiceemergency medicinediagnosticproceduralcitalopram
SApolice custody2006-12-18

Coroner's Finding: BAYLIS Julia Marie

30y · Female·bronchopneumonia complicating anoxic encephalopathy due to neck compression due …

Julia Marie Baylis, a 30-year-old woman, died from bronchopneumonia complicating anoxic encephalopathy due to hanging after being placed in custody at Elizabeth Police Station. Critical failures in prisoner supervision a…

communicationsystemalcohol
QLDcommunity2006-12-15

Barlow, Charles Edward; Lusk, Patrick Douglas; Baggott, Emily Jane

asphyxia sequential to hanging (all three cases); Charles Barlow: schizophrenia …

Three linked suicide cases spanning February 2004 to October 2005 in Far North Queensland mental health services. Charles Barlow (36, Aboriginal) was denied admission despite requesting transfer to Cairns Base Hospital M…

psychiatrygeneral practicediagnosticcommunicationflupenthixol
SAcommunity2006-12-13

Coroner's Finding: ELDRIDGE Michael and GERARD David

Multiple stab wounds to chest (David Gerard: stab wound to chest piercing heart;…

Joint inquest into two homicides by individuals with schizophrenia who were managed by mental health services. Anthony Butler stabbed David Gerard in 2001 after being discharged from Glenside Hospital without Community T…

psychiatryemergency medicinecommunicationsystemzuclopenthixol deconate
WAhospital2006-12-05

Inquest into the Death of Steele

63y · Male·ruptured abdominal aortic aneurysm

Norman Eric Keith Steele, 63 years old, collapsed at work on 28 May 2004 and was transported to Merredin District Hospital at 9:10am with a presenting complaint of severe abdominal pain (9/10) radiating to his back, dizz…

emergency medicinegeneral practicediagnosticdelayhyoscine butylbromide

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