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WAcommunity2001-12-19

Inquest into the Death of Martin Raymond Coffey

24y · Male·Aspiration of vomit associated with combined drug effect

Martin Raymond Coffey, 24, died from aspiration of vomit associated with combined drug effect while on home detention after serving a prison sentence for traffic offences. He had a history of depression (following the de…

psychiatrygeneral practicesystemcommunicationamitriptyline
WA2001-11-19

Inquest into the Death of Adam Timothy Garner

18y · Male·Ligature Compression of Neck (Hanging)

Adam Timothy Garner, aged 18½, died by hanging in his prison cell at Canning Vale Prison Complex on 6 January 2000, approximately 24 hours after admission. He was on remand for a serious violent offence and was experienc…

correctional healthpsychiatrysystemcommunicationprescription medication for alcohol and drug withdrawal
SAhospital2001-11-09

Coroner's Finding: BALL Norman Samual Dean

35y · Male·neck compression from hanging

A 35-year-old man with a history of depression, substance abuse, and acquired brain injury from assault was admitted to a psychiatric ward after self-harm with suicidal ideation. He was detained under the Mental Health A…

psychiatrygeneral practicecommunicationsystemcarbamazepine
NTcommunity2001-10-19

Inquest into the death of Clive Henry Impu

25y · Male·coronary thrombosis resulting from coronary atherosclerosis

A 25-year-old Aboriginal man with undiagnosed coronary artery disease collapsed and died one hour after a consultation at an Aboriginal health clinic. The coroner found the medical examination by Dr M. was inadequate and…

general practiceemergency medicinediagnosticcommunicationanti-inflammatory medications
NT2001-10-16

Inquest into the death of Christopher Limerick

20y · Male·Unable to be determined. Death likely resulted from exposure following a fall wh…

Christopher Limerick, a 20-year-old Aboriginal man with alcohol dependency, was found dead at the bottom of Noble's Nob open-cut mine near Tennant Creek. Despite extensive investigation, the cause of death could not be d…

forensic medicineemergency medicinecommunicationsystem
NTPodcast2001-10-15

Inquest into the death of Bryan G (aka) Abell Dallos

25y · Male·multiple injuries sustained in aircraft crash

Bryan G (Abel Dallos), a 25-year-old man with longstanding paranoid schizophrenia and treatment resistance, died in an aircraft crash after stealing an unlocked Piper Warrior from Alice Springs Airport and attempting to …

psychiatryaviation medicinecommunicationsystemhaloperidol
SAcommunity2001-10-05

Coroner's Finding: BEDNAREK Shantel Lisa

7y · Female·Multiple abdominal injuries including traumatic rupture of the liver and stomach…

A 7-year-old girl died from massive abdominal injuries sustained when a car, driven by an insulin-dependent diabetic man, collided with a group of pedestrians. The driver had undiagnosed and unaware hypoglycemia at the t…

endocrinologyemergency medicinediagnosticcommunicationinsulin
SAhospital2001-09-07

Coroner's Finding: SANDS Celia Laurel

82y · Female·peritonitis due to a perforated viscus (proximal jejunum) resulting from motor v…

An 82-year-old woman suffered a motor vehicle accident causing blunt abdominal trauma. Despite initial clinical assessment appearing adequate, a perforated jejunum with developing peritonitis was not diagnosed until earl…

general surgeryemergency medicinediagnosticdelay
SAhospital2001-08-24

Coroner's Finding: GADALETA Saverio

28y · Male·Peritonitis and septic shock complicating perforation of the terminal small bowe…

A 28-year-old man with cerebral palsy, microcephaly, and epilepsy presented to the ED with abdominal pain, fever, and signs of deterioration. Triaged as Priority 3 despite these concerning features, he was not seen by a …

emergency medicinegeneral surgerycommunicationdelayparacetamol
ACT2001-08

Inquest Into The Manner And Cause Of Death Of Brett Ponting

33y · Male·Cerebral hypoxia caused by drowning

A 33-year-old man with severe intellectual disability and cerebral palsy drowned in a bath at a supported accommodation house. Carers left him unattended in the bath despite an Individual Plan stating 'full assistance re…

geriatric medicineemergency medicinecommunicationsupervision
SAhospital2001-07-13

Coroner's Finding: TRIMBOLI Jayden Tyler

0y · Male·hypoxic-ischaemic encephalopathy due to prolonged fetal bradycardia

Jayden Tyler Trimboli, aged 6 days, died from hypoxic-ischaemic encephalopathy caused by a prolonged fetal bradycardia episode between 11:10pm and 11:50pm on 18 September 1998. The critical failure was that the cardiotoc…

obstetricsmidwiferycommunicationsystemprostaglandin gel
SAhospital2001-05-16

Coroner's Finding: KLOSE Glen Malcolm

71y · Male·Saddle pulmonary embolus as a consequence of deep venous thrombosis in the right…

Glen Malcolm Klose, aged 71, died from a saddle pulmonary embolus secondary to deep vein thrombosis in his right calf, a complication associated with his history of multiple knee surgeries. He was admitted to Glenside Ho…

psychiatrygeneral medicinedelay
SAhospital2001-05-04

Coroner's Finding: ROACH Dawn Ruth

45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…

A 45-year-old woman died from multi-organ failure following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (1.5 cm) was contained and re…

colorectal surgerygeneral surgeryproceduralcommunication
NThome2001-01-25

Inquest into the death of Eduardo Concepcion

26y · Male·multiple gunshot wounds with death resulting from combination of blood loss and …

Eduardo Concepcion, a 26-year-old man experiencing mental health crisis and acute intoxication, died from multiple gunshot wounds inflicted by Northern Territory Police. Following days of deteriorating mental state, self…

emergency medicinepsychiatrysystemcommunicationmogodons
SAmental health2000-12-12

Coroner's Finding: FELSTEAD Christopher John

33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes

A 33-year-old man with major depressive disorder and multiple suicide attempts died by carbon monoxide poisoning after premature discharge from psychiatric inpatient care. He was admitted to Lyell McEwin Health Service o…

psychiatryemergency medicinediagnosticcommunicationcarboxyhaemoglobin
SA2000-11-28

Coroner's Finding: STURT Royston Henry

58y · Male·hanging

A 58-year-old man remanded in custody awaiting trial died by hanging in prison. He had a history of depression treated with fluoxetine and was assessed by a forensic psychiatrist who found no evidence of depression or su…

psychiatrygeneral medicinecommunicationsystemfluoxetine
SAhospital2000-11-20

Coroner's Finding: MIDDLETON Geraldine Ruth

45y · Female·haemorrhage due to traumatic rupture of the liver

A 45-year-old woman with a long history of bipolar disorder and personality disorder presented to the ED at 2:30 AM after cutting her wrist deeply with a carving knife. The treating casualty officer did not properly docu…

emergency medicinepsychiatrydiagnosticcommunicationdiazepam
SAmental health2000-11-14

Coroner's Finding: SIMMONETTE Sean Patrick

26y · Male·respiratory arrest complicating hydrocarbon inhalation (sudden sniffing death)

A 26-year-old man with schizophrenia, antisocial personality disorder, and polysubstance abuse died from sudden sniffing death syndrome after inhaling fly spray in a psychiatric ward smoking room. Three days prior, staff…

psychiatryforensic medicinecommunicationsystemchlorpromazine
SAaged care2000-11-07

Coroner's Finding: CZEKAJLO Helena

69y · Female·Respiratory obstruction by aspirated food (Brussels sprout, chicken and carrots)…

Helena Czekajlo, aged 69, died from respiratory obstruction by aspirated food (Brussels sprout) at a nursing home. She had dementia and schizophrenia with a documented obsession about food and tendency to eat hurriedly. …

geriatric medicineemergency medicineproceduralcommunicationfluphenazine decanoate
NThospital2000-10-31

Inquest into the death of Corey Paddy

25y · Male·positional asphyxia in a man with extensive old hypoxic brain damage, acute ches…

Corey Paddy, a 25-year-old Aboriginal man with severe hypoxic brain injury from a 1998 car accident, died at Katherine Hospital from positional asphyxia while receiving concurrent morphine therapy and suffering from acut…

orthopaedic surgeryneurologycommunicationsystemmorphine

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