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NSWhome2023-07-05

Inquest into the death of JY

5y · Male·multiple stab wounds

A 5-year-old boy died from multiple stab wounds inflicted by his father during an acute psychotic episode. The father, diagnosed with schizophrenia in 2003, was admitted to Hornsby Hospital in April 2018 following deteri…

psychiatrygeneral practicecommunicationsystemrisperidone
TAS2023-07-05

Coroner's Finding: Crump, Damian Michael

36y · Male·Mixed prescription drug toxicity (morphine, lignocaine, amiodarone and midazolam…

Damian Crump, aged 36, was an intensive care paramedic with Ambulance Tasmania who died by suicide on 23 December 2016 by deliberately consuming fatal quantities of morphine, lignocaine, amiodarone and midazolam stolen f…

paramedicinepsychiatrysystemdelaymorphine
VIChome2023-06-30

Finding into death of John Salemme

48y · Male·Cardiac hypertrophy, combined with effects of gamma hydroxybutyrate and amphetam…

A 48-year-old man with previously undetected cardiac hypertrophy died from a combination of cardiac arrhythmia triggered by illicit drug use (GHB and amphetamines). He collapsed at a friend's house after drug ingestion a…

emergency medicineforensic medicinecommunicationdelaygamma hydroxybutyrate
QLDhospital2023-06-30

Booth, Yvette and Sandy, Adele and George, Shakaya (“RHD Doomadgee Cluster”)

Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…

This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…

cardiologyemergency medicinecommunicationsystempenicillin
WAhospital2023-06-29

Inquest into the Death of Child R (Name Subject to Suppression Order)

11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…

Child R, an 11-year-old Aboriginal girl with congenital anorectal anomalies causing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and vomiting. She died 12 ho…

paediatricsemergency medicinediagnosticcommunicationmacrogol
VICaged care2023-06-27

Finding into death of Elizabeth Ethel Watson

89y · Female·Complications of fractured neck of femur in the setting of a fall in a woman wit…

An 89-year-old woman with dementia and high falls risk sustained a fall at an aged care facility on 24 August 2019. The enrolled nurse in charge, on her third unsupervised shift, lacked electronic medical record access a…

geriatric medicineemergency medicinediagnosticcommunicationtramadol
TASaged care2023-06-27

Coroner's Finding: Guy, Peter Joseph

82y · Male·hypostatic pneumonia

An 82-year-old man with dementia and multiple comorbidities died of hypostatic pneumonia following complications from a fall at a residential aged care facility. He sustained an L2 compression fracture from an unwitnesse…

geriatric medicineemergency medicinesystemprocedural
QLDhospital2023-06-26

Searle, William Edward

74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …

William Searle, a 74-year-old prisoner, died from aspiration of gastric contents following a Whipple procedure for recurrent ampullary adenoma. The clinical lessons involve recognition of gastroparesis risk in high-risk …

general surgeryintensive carediagnosticcommunicationadrenaline
NSWhospital2023-06-23

Inquest into the death of Baylen Pendergast

21y · Male·Complications of blunt head injury resulting from at least two separate acts of …

Baylen Pendergast, 21 months old, died from complications of blunt head injury sustained in two separate traumatic incidents (17 and 28 November 2013). The coroner found injuries were non-accidental and resulted from sig…

paediatricsemergency medicinediagnosticcommunication
VIC2023-06-22

Finding into death of Cherie Virginia Pearl Guest

61y · Female·Diffuse alveolar damage in a woman with restrictive lung disease following catar…

A 61-year-old woman with severe restrictive lung disease, obesity, cardiac failure, and diabetes underwent cataract surgery at a private day surgery centre on 13 August 2018. She was unable to lie flat and became hypoxic…

ophthalmologyanaesthesiadiagnosticcommunicationlidocaine
VIChome2023-06-08

Finding into death of Mayumi Spencer

29y · Female·Cocaine toxicity

Mayumi Spencer, a 29-year-old woman, died from cocaine toxicity on 17 January 2015. At approximately 4:00 AM, her husband Dr S. discovered her having a seizure and vomiting. Rather than immediately calling emergency serv…

emergency medicinetoxicologydelaysystemcocaine
TAShospital2023-05-31

Coroner's Finding: Richardson Rebecca Eileen

29y · Female·acute myocardial infarction due to stenotic coronary vessel (left anterior desce…

Rebecca Richardson, a 29-year-old with type 1 diabetes and coronary artery disease, died of acute myocardial infarction on 7-9 May 2019. She presented to NWRH ED on 6 May with abdominal pain and vomiting, initially attri…

emergency medicinecardiologydiagnosticcommunicationinsulin
NSW2023-05-26

Inquest into the death of Azhar Abdul

26y · Male·hanging

Azhar Abdul, aged 26, died by hanging in Bathurst Correctional Complex while in protective custody. He had requested removal from the Honour House program on 27 February 2022, citing external threats and a debt to motorc…

forensic medicinecorrectional healthcommunicationsystem
WAhospital2023-05-26

Inquest into the Death of Jacob George Isaac TAULELEI

28y · Male·Multiple injuries sustained when struck by a freight train

Jacob Taulelei, a 28-year-old man with long-standing depression, anxiety, and suicidal ideation, presented to St John of God Hospital on 5 February 2020 expressing intent to jump in front of a train. Despite being assess…

psychiatryemergency medicinediagnosticcommunicationduloxetine
NSWcommunity2023-05-25

Inquest into the disappearance and suspected death of Melissa CADDICK

49y · Female·Cannot be determined

Melissa Caddick, a financial advisor running a Ponzi scheme, disappeared on 12 November 2020 after ASIC executed a search warrant at her home. Her decomposed foot washed ashore 100 days later. Clinical lessons emerge: th…

psychiatryforensic medicinedelaysystem
VIChome2023-05-25

Finding into death of Emma Gertrude Weidemann

76y · Female·Effects of fire in a woman with head and neck injuries

Mrs Emma Weidemann, aged 76, died from burns sustained in a fire deliberately set by her husband Rudolf at their home on 11 December 2019. Rudolf had recently been diagnosed with terminal cancer, experienced cognitive de…

oncologypsychiatrydiagnosticcommunicationvenlafaxine
VIChome2023-05-25

Finding into death of Bradley Scott Liefvoort

46y · Male·Opioid toxicity (tapentadol and oxycodone)

Bradley Liefvoort, 46, died from opioid toxicity (tapentadol and oxycodone) at home in Dandenong. Over a decade of prescription medication misuse began with ibuprofen for headaches, escalating to opioid dependence follow…

general practicepain medicinemedicationsystemtapentadol
VIChospital2023-05-24

Finding into death of Mr V

73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…

A 73-year-old man presented to ED with acute facial droop and speech difficulty on 5 September 2020. He was misdiagnosed with Bell's palsy despite clinical features suggestive of stroke. A non-contrast CT brain (inadequa…

emergency medicineneurologydiagnosticcommunicationprednisolone
NSW2023-05-23

Inquest into the death of JS

34y · Male·Plastic bag asphyxia

A 34-year-old man on remand died by plastic bag asphyxia at Shortland Correctional Centre on 5 May 2020, hours before his release on bail. He had disclosed anxiety and depression, made multiple self-referrals for mental …

psychiatrypsychologydiagnosticcommunication
TAS2023-05-22

Coroner's Finding: Hyde-Wyatt, Michael Phillip

61y · Male·Pulmonary aspiration of gastric contents (post seizure) due to chronic communica…

Michael Phillip Hyde-Wyatt, aged 61, died from pulmonary aspiration of gastric contents following a seizure. He had chronic communicating hydrocephalus and encephalomalacia. At 1:30am, support worker Julie Magrath observ…

general practiceneurologycommunicationdelay

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