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ACTcommunity1999-02-26

In The Matter Of The Death Of Warren Geoffrey Ianson

Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…

Warren I'Anson died from gunshot wounds to the mid-back on 17 November 1995 during a police response to a mental health crisis. He had schizophrenia, recently experienced grief from his wife and friend's deaths, and was …

psychiatryemergency medicinecommunicationsystemdiazepam
ACTcommunity1999

Inquest Into The Death Of Katie Bender

12y · Female·Head injury caused by high-velocity steel fragment missile, approximately 999 gr…

Katie Bender, aged 12, was struck fatally in the head by a 999-gram steel fragment while watching the controlled implosion of Royal Canberra Hospital on 13 July 1997. The fragment travelled 430 metres in 3.1 seconds at 1…

occupational and environmental healthdiagnosticprocedural
NTcommunity1998-09-02

Inquest into the death of Esky Muller

14y · Male·Loss of blood arising from incised wound to the left arm (cubital fossa)

A 14-year-old Aboriginal petrol sniffer brought to a remote outstation (Ilpurla) without pre-arrangement died from massive haemorrhage following a self-inflicted laceration to his arm. Clinical lessons: petrol sniffers i…

emergency medicineaddiction medicinediagnosticsystempetrol
ACThospital1998-07-16

Inquest Into The Death Of Nathan Thomas James Wrench

0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…

Nathan Wrench, 11 weeks old, presented to Queanbeyan Hospital on 14 October 1996 with persistent vomiting for 3 days. GP Dr R. diagnosed viral infection with possible reflux, admitted for observation, and managed conserv…

paediatric surgeryemergency medicinecommunicationdiagnostic
ACThome1998-03-06

Inquest Into The Circumstances Surrounding The Death Of Brian Joseph Duff

36y · Male·Toxic overdose of Clozapine (anti-psychotic drug), self-administered, with termi…

Brian Duff, a 36-year-old with severe chronic schizophrenia, died from Clozapine toxicity (pulmonary oedema and cardiac arrest) on 14-15 February 1997. He was subject to a Community Treatment Order and under case managem…

psychiatrycommunicationsystemclozapine
ACT1997

Inquest Into The Circumstances Surrounding The Death Of Shannon Robert Camden

21y · Male·Suffocation from hanging

Shannon Robert Camden, a 21-year-old with longstanding mental health difficulties and previous suicide attempts, died by hanging in cell A1 of the Belconnen Remand Centre on 15 April 1996 while on remand awaiting trial f…

psychiatrypsychologyproceduralsystem
TAShospital1996-10-01

Coroner's Finding: Muller Shar Marie

25y · Female·injuries sustained by jumping from the Tasman Bridge

A 25-year-old woman with longstanding borderline personality disorder, chronic suicidal ideation, and substance abuse died by jumping from the Tasman Bridge on 4 January 1996. She presented to the Emergency Department on…

psychiatryemergency medicinecommunicationsystemflunitrazepam
VIChospital1996-08-16

LONG June

69y · Female·Asthma

June Sylvia Long, aged 69, suffered an asthma attack at home on 28 June 1994 and was transported to Alfred Hospital. She deteriorated overnight in the hospital's Respiratory Ward despite initial improvement in Emergency …

respiratory medicineemergency medicinediagnosticcommunicationsalbutamol
NTcommunity1991-06-03

Inquest into the death of Ganamu Garrawurra

48y · Male·shotgun wound to the head

A 48-year-old Yolngu man with chronic mental illness (schizophrenia) died from a shotgun wound to the head on Elcho Island, NT in April 1990. After spearing two people with a fishing spear, police Task Force was called t…

psychiatryforensic medicinesystemcommunicationmelleril
WA28 Mar 24

Inquest into the Death of Suzzanne Denise DAVIS

47y · Female·ligature compression of the neck (hanging)

A 47-year-old woman remanded in custody at Melaleuca Women's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior…

psychiatryemergency medicinecommunicationsystemmethadone
WA

Inquest into the Death of Stanley John INMAN

19y · Male·complications of ligature compression of the neck

Stanley John Inman, 19-year-old Aboriginal male, died by suicide at St John of God Midland Hospital on 13 July 2020, two days after ligature compression of the neck at Acacia Prison. He was on low-level ARMS (at-risk man…

psychiatrypsychologycommunicationsystemmirtazapine
WAhome

Inquest into the Death of Baby AM

0y · Male·severe hypoxic ischaemic encephalopathy secondary to uterine rupture

Baby AM died from severe hypoxic ischaemic encephalopathy secondary to uterine rupture during a planned home vaginal birth after caesarean (VBAC). The mother, Ms M, was 40 weeks and 5 days pregnant, attended by a private…

obstetricsmidwiferydiagnosticcommunication
WA

Inquest into the Death of Jarrod Arthur HAMPTON

22y · Male·drowning secondary to incapacitation from air embolism

A 22-year-old skilled and experienced pearl shell drift diver with over 600 logged dives died from drowning secondary to air embolism and cerebral arterial gas embolism while diving for Paspaley Pearling Company off Broo…

diving medicineoccupational and environmental healthsystemdelay
WAcommunity

Inquest into the Death of Gary John LYDDIETH

54y · Male·Unknown - death established on balance of probabilities but manner and cause und…

A 54-year-old man with major depressive disorder, chronic suicidality, and alcohol abuse was discharged from psychiatric hospital on 23 April 2014 while remaining at "very high chronic suicide risk." He had multiple prio…

psychiatrygeneral medicinesystemcommunication
WAcommunity

Inquest into the Death of Dean Anthony POLLARD

41y · Male·unknown

Dean Anthony Pollard was a 41-year-old man with a long history of schizophrenia and amphetamine-induced psychotic disorder who disappeared in May-June 2010 and is presumed dead. He had multiple psychiatric admissions bet…

psychiatryemergency medicinesystemcommunicationmethamphetamine
WAcommunity

Inquest into the Death of Petronella ALBERT

22y · Female·Unable to determine - open finding

Petronella Albert, a 22-year-old Aboriginal woman from Broome, disappeared in late April or early May 1999 and is presumed deceased. The coronial inquest, conducted in 2017, established her death beyond reasonable doubt …

systemdelay
WAhome

Inquest into the death of Nicole Emily BICKNELL

18y · Female·Acute Alcohol Toxicity with Early Pneumonia and Aspiration

An 18-year-old female, a naive drinker, consumed approximately 19-21 standard drinks over a few hours at her birthday party, including vodka cruisers, a full-strength Midori drinking game, and Polmos (95% alcohol). She r…

toxicologyemergency medicinedelaysystemalcohol
WAhospital

Inquest into the Death of June Valerie LOBBAN

69y · Female·Intra-abdominal sepsis and shock with multi-organ failure following intestinal p…

A 69-year-old woman died from intra-abdominal sepsis and multi-organ failure following a perforated caecum that occurred after lumbar spine surgery. Post-operatively, she developed abdominal distension and pain initially…

neurosurgerygeneral surgerydiagnosticdelayfentanyl
WAhospital

Inquest into the death of Amanda Dana TAUAI

21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)

Amanda Dana Tauai, 21 years old, died from septic shock with multi-organ failure in March 2012 after presenting with symptoms initially consistent with viral gastroenteritis and dehydration. Initial management at remote …

general practiceemergency medicinediagnosticcommunicationmetoclopramide
WAaged care

Inquest into the Death of Nola Inez DANIEL

83y · Female·Complications following fracture and surgical repair of the left hip in an elder…

Mrs Nola Inez Daniel, an 83-year-old with chronic lung disease, osteoporosis, and cardiac disease, was admitted to Regis Forrest Gardens for respite care on 24 December 2009. She sustained three falls on Christmas Day, w…

orthopaedic surgeryemergency medicinediagnosticcommunicationfentanyl

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