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NThospital2000-10-31

Inquest into the death of Marcio Jose Lay Nheu

26y · Male·Closed head injury with extradural and subdural haemorrhage resulting from a sku…

26-year-old Marcio Jose Lay Nheu died from a closed head injury with extradural haemorrhage caused by a blow to the head with a Maglite torch at Karama Shopping Centre. He was struck by Rodney Foster during an altercatio…

emergency medicineneurosurgerydiagnosticcommunicationtemazapam
SAhome2000-09-15

Coroner's Finding: DONAGHEY Luke Francis

26y · Male·.357 magnum gunshot wounds to the chest and abdomen

Luke Donaghey, a 26-year-old man with untreated psychotic illness, was shot by police after threatening his parents with a knife. Critical clinical lesson: his general practitioner failed to utilize available mental heal…

general practicepsychiatrydiagnosticcommunicationhaloperidol
NThospital2000-09-06

Inquest into the death of Francis Kamaranga

28y · Male·asphyxiation following severe swelling to the larynx due to anaphylactoid reacti…

A 28-year-old Aboriginal male died from anaphylactoid reaction to Haemaccel, a plasma volume expander administered pre-hospital following a severe laceration to the radial artery. Initial management was appropriate, but …

emergency medicineintensive carediagnosticdelayhaemaccel
SAhospital2000-07-21

Coroner's Finding: DRESCHLER Michelle Lee

27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…

A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…

general surgerygeneral practiceproceduralcommunicationdiazepam
SAhospital2000-07-21

Coroner's Finding: HOWIESON Julie Ann

43y · Female·sepsis secondary to extensive acute peritonitis following perforation of small b…

43-year-old woman died from sepsis and necrotising fasciitis following small bowel perforation during laparoscopic tubal ligation. She was at high risk due to previous abdominal surgeries and adhesions. A 4-5mm perforati…

gynaecologyanaesthesiadiagnosticdelay
SA2000-06-16

Coroner's Finding: CARTER Marshall Freeland

19y · Male·heroin toxicity

Marshall Carter, 19, died in custody from heroin toxicity at Yatala Labour Prison. He had a long history of drug abuse starting from age 14 and was an intravenous heroin user. Critical failures included: inadequate trans…

forensic medicineemergency medicinediagnosticcommunicationheroin
SAhospital2000-06-16

Coroner's Finding: WANGANEEN Fallon

26y · Male·neck compression due to hanging

A 26-year-old Aboriginal man with longstanding borderline personality disorder, substance abuse, and multiple suicide attempts died by hanging in a psychiatric ward whilst detained under a Mental Health Act order. Key cl…

psychiatryemergency medicinediagnosticcommunicationparacetamol/codeine
NThome2000-06-01

Inquest into the death of Trevor Parkyn

37y · Male·Traumatic intracranial haemorrhages/brain damage and fractured skull

A 37-year-old male died from traumatic intracranial haemorrhage and skull fracture after being punched and falling onto concrete. The critical clinical lesson is that head injuries may be completely undetectable on exter…

forensic medicineemergency medicinediagnosticalcohol
WAcommunity2000-05-18

Inquest into the Death of Syoko Tsubaki

24y · Female·Immersion (drowning due to hypoxic brain injury)

Syoko Tsubaki, a 24-year-old Japanese tourist and inexperienced recreational diver, died from drowning on 31 December 1998 after a scuba diving incident at Rottnest Island on 27 December. During an afternoon dive, the di…

diving medicineemergency medicinecommunicationprocedural
SAhospital2000-04-28

Coroner's Finding: SODY Caleb

20y · Male·ruptured heart and aorta due to fall from a height

A 20-year-old male with newly diagnosed disorganised schizophrenia died by suicide from a fall from the 5th floor of a hospital maternity building while detained under the Mental Health Act. He had been admitted to the C…

psychiatryemergency medicinesystemdelayolanzapine
NThospital2000-04-10

Inquest into the death of Baby J

0y · Female·premature delivery; extreme prematurity

A 19-week pregnant woman was admitted for pregnancy termination due to maternal psychological concerns. Labour was induced with misoprostol, expecting foetal death in utero or delivery of non-viable remains. Instead, a l…

obstetricsmidwiferycommunicationsystemmisoprostol
SAmental health2000-04-07

Coroner's Finding: SANDERS Sandra June

42y · Female·salt water drowning

Sandra Sanders, aged 42, a detaineε psychiatric patient, died by saltwater drowning after absconding from Woodleigh House psychiatric unit on 3 September 1997. She had presented with major depression with psychotic featu…

psychiatrycommunicationsystemstelazine
WA2000-04-07

Inquest into the Death of Kenneth John Groth

47y · Male·Ligature compression of the neck (hanging)

Kenneth John Groth, aged 47, died by hanging in Casuarina Prison on 9 April 1998. He was a sentenced prisoner convicted of sexual offences, serving a 10-year sentence. His appeal was adjourned and legal aid was refused, …

psychiatrycorrectional healthdiagnosticfluoxetine
WAmental health2000-03-21

Inquest into the Death of Lorna Silvester

27y · Female·Ligature compression of neck (hanging)

Lorna Silvester, a 27-year-old woman with depression and suicidal ideation, died by hanging on 18 January 1999 while on approved leave from Graylands Hospital. She had been admitted involuntarily on 13 January after pres…

psychiatrycommunicationsystemhaloperidol
SAcommunity2000-03-13

Coroner's Finding: STRANGWAYS Kenneth Charles

34y · Male·aspiration pneumonia following seizure with concomitant global severe anoxic enc…

Kenneth Strangways, a 34-year-old Aboriginal man with post-traumatic epilepsy, organic brain damage from head injuries, alcoholism and psychiatric illness, died from aspiration pneumonia following a seizure. The death wa…

psychiatryneurosurgerycommunicationsystemanticonvulsant medications
WAhome2000-03-10

Inquest into the Death of Michael James Dwyer

30y · Male·acute combined heroin and alcohol toxicity; ingestion of alcohol and heroin

Michael James Dwyer, a 30-year-old man, died on 17 June 1999 at Royal Perth Hospital from acute combined heroin and alcohol toxicity. On 11 June, after returning from Melbourne, he consumed approximately one litre of gin…

emergency medicineintensive caredelayheroin
SAhospital2000-02-25

Coroner's Finding: STONEHOUSE Jarrod William (aka Scott)

23y · Male·aspiration of blood due to stab wound to trachea

23-year-old man with self-inflicted stab wound to neck presenting to emergency department while intoxicated and agitated. Ambulance noted 3cm laceration to midline trachea with minimal external bleeding. Registered nurse…

emergency medicinesurgerydiagnosticcommunicationalcohol
WA2000-02-11

Inquest into the Death of Sean Kevin Hayes

24y · Male·plastic bag asphyxiation

Sean Kevin Hayes, a 24-year-old male remand prisoner, died from plastic bag asphyxiation in his cell at Canning Vale Remand Centre in Western Australia on 20-21 August 1997. He had a history of psychiatric illness, previ…

psychiatrycorrectional healthsystemcommunicationstelazine
ACT1999-08-05

In The Matter Of An Inquest Into The Death Of Ian Glen Bransby At Canberra On 14.2.98

31y · Male·extensive global cerebral hypoxia following prolonged asphyxia following attempt…

Ian Glen Bransby, a 31-year-old remandee with a history of substance abuse and depression, died from asphyxia following attempted hanging at Calvary Hospital on 14 February 1998. He had been remanded at Belconnen Remand …

psychiatrygeneral practicecommunicationsystemchlorpromazine
ACT1999-06-28

Inquest Into The Manner And Cause Of Death Of Mark Robert Watson

17y · Male·Cerebral ischaemia caused by hanging at Quamby Youth Detention Centre at approxi…

Mark Watson, a 17-year-old boy charged with assault, was detained at Quamby Youth Detention Centre. During his second remand in September 1996, after a failed hospital admission, he returned to the same unit where he had…

psychiatrypsychologysystemsupervision

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