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QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

Teresa Bradford, aged 40, was killed by her husband David Bradford in a premeditated domestic homicide at their Pimpama home on 31 January 2017, followed by his suicide. She died from head injuries inflicted with an axe.…

general practicepsychiatrycommunicationsystemwarfarin
NSWcommunity2021-05-21

Inquest into the death of Pono Wairua Aperahama

17y · Male·Cardiac arrhythmia during restraint, with previous traumatic brain injury as a s…

Pono Aperahama, a 17-year-old with severe traumatic brain injury and moderate intellectual disability, died from cardiac arrhythmia during restraint at a swimming pool. His escalating behaviour in 2017—triggered by schoo…

neurologypsychiatrysystemcommunication
WAhome2021-04-16

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

3y · Female·tramadol toxicity

A 3-year-old girl in state care died from tramadol toxicity after accessing prescribed opioid medication left unsecured in her carer's bedroom. The child was removed from her mother's care due to neglect and substance ab…

paediatricsforensic medicinesystemdelaytramadol
VIChospital2021-02-05

Finding into death of Carl David Waldon

64y · Male·Left-sided intracerebral haemorrhage associated with deep brain stimulator wire …

A 64-year-old man died from intracerebral haemorrhage along a deep brain stimulator wire tract four days after elective neurosurgery for essential tremor. He was readmitted on day 4 with suspected stroke and started on t…

neurosurgeryneurologymedicationsystemenoxaparin
WAhospital2020-09-23

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

5y · Female·aspiration of vomit with microscopic early pneumonia, in a child with a history …

A five-year-old girl with cerebral palsy and epilepsy resulting from non-accidental head injuries at two months old died from aspiration of vomit with early pneumonia. Critical lessons: bruising in non-ambulant infants i…

paediatricsgeneral practicediagnosticcommunicationtopiramate
NSW2020-08-26

Inquest into the death of Tane Chatfield

22y · Male·hypoxic ischaemic encephalopathy as a result of hanging

Tane Chatfield, a 22-year-old Aboriginal man, died by hanging in his prison cell at Tamworth Correctional Centre on 20 September 2017. He had been admitted to hospital the preceding night with seizures, assessed as unlik…

emergency medicineneurologydiagnosticcommunicationparacetamol
TAShome2020-07-17

Coroner's Finding: Thompson, Paul Christopher

57y · Male·acute subdural haematoma, cause undetermined (could result from trauma, fall, se…

Paul Thompson, aged 57, died from acute subdural haematoma (brain bleeding). He was found unresponsive after an evening of heavy alcohol consumption with his housemate Lawrence Kean, who punched him during an altercation…

forensic medicineneurologydelayalcohol
QLDcommunity2020-06-26

Nyholt, Nicole Sonia and Clark, Margaret Louisa

Female·Burns due to gas explosion due to motor vehicle collision with building

A 60-year-old man with a long-standing history of seizures experienced an epileptic seizure while driving and lost control of his vehicle. It collided with an LPG gas cylinder outside a café, triggering an explosion that…

emergency medicineneurologycommunicationsystem
VICaged care2020-06-03

Finding into death of Annette Lee Douglass

60y · Female·Respiratory arrest in the setting of aspiration pneumonia; seizures associated w…

A 60-year-old woman with Down syndrome, Alzheimer's dementia, and epilepsy died from respiratory arrest due to aspiration pneumonia after a seizure. A multi-day delay in anticonvulsant medication (phenytoin) occurred due…

general practiceneurologycommunicationsystemphenytoin
TAShospital2020-04-07

Coroner's Finding: Pettersson, Jan Axel

71y · Male·disseminated fungal (Cryptococcus) infection of the lungs, brain and meninges

A 71-year-old man presented with fever, confusion, and gait disturbance in October 2017. A lung mass was identified on chest X-ray and presumed malignant, but inflammatory markers were unremarkable. Despite clinical dete…

general medicinerespiratory medicinediagnosticdelay
VIC2020-04-06

Finding into death of Darren Brandon

51y · Male·hypoxic-ischemic encephalopathy due to hanging

Darren Brandon died by hanging in prison on 10 June 2018, two days after arriving at Melbourne Assessment Prison. He was a 51-year-old man with acquired brain injury from a 2003 motorcycle accident, depression, and histo…

psychiatryforensic medicinecommunicationsystemoxycodone
VIChospital2020-02-28

Finding into death of Keith Walter Sharp

63y · Male·Cerebral infarction complicating vertebral artery dissection following motor veh…

Keith Walter Sharp, 63, sustained a motor vehicle collision causing vertebral artery dissection and subsequent cerebral infarction. At Albury Base Hospital, initial CT imaging at 10:44am identified significant cervical s…

emergency medicineradiologydelaydiagnosticaspirin
NSW2020-02-28

Inquest into the death of Eric WHITTAKER

35y · Male·subarachnoid haemorrhage with antecedent ruptured cerebral artery aneurysm

Eric Whittaker, a 35-year-old Aboriginal man, died from a subarachnoid haemorrhage caused by a ruptured cerebral artery aneurysm while in remand custody at Parklea Correctional Centre. On 2 July 2017, he made 20 emergenc…

correctional healthneurologydiagnosticcommunicationamphetamine
NSWhospital2020-01-31

Inquest into the death of OS

5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …

A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…

plastic and reconstructive surgeryanaesthesiamedicationproceduralmorphine
VIChome2020-01-14

Finding into death of H B

8y · Female·Aspiration pneumonia in a child with an epileptic encephalopathy and extreme cac…

HB, age 8 years 10 months, died from aspiration pneumonia with extreme cachexia (BMI 7). She had severe cerebral palsy, epilepsy (Lennox-Gastaut syndrome), and was entirely dependent on PEG tube feeding. Between January …

paediatricsneurologydiagnosticdelaylevetiracetam
VICaged care2020-01-13

Finding into death of Annie Chettle

74y · Female·Subdural haemorrhage following a fall in a woman with multiple medical comorbidi…

Mrs Chettle, a 74-year-old aged care resident with multiple comorbidities including dementia, schizoaffective disorder, and a nine-fall history in twelve months, fell from a shower chair while a personal care assistant b…

geriatric medicineemergency medicinediagnosticcommunication
NSWhospital2019-12-17

Inquest into the death of Alan BUGDEN and Amaru BESTRIN

Unknown·Alan Bugden: pulmonary thromboembolism after stroke. Amaru Bestrin: combined dru…

Two deaths occurred in hospital toilets due to undetected collapse in publicly accessible facilities. Alan Bugden, 66, suffered a stroke in an ambulatory care centre toilet at Royal North Shore Hospital and remained unde…

emergency medicineneurologysystemcommunicationheroin
QLDhome2019-11-06

Follent, Mitchell James - Non-inquest findings

22y · Male·Multiple injuries from fall from height

Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired b…

psychiatryneurologydiagnosticcommunicationolanzapine
ACThospital2019-08-22

Inquest into death of Sebastian Nicholas Pelle

20y · Male·sudden unexplained death in epilepsy (SUDEP); right frontal lobe epidermal cyst …

A 20-year-old man with a history of seizures and a previously resected frontal lobe cyst presented to hospital with severe headaches. Despite his significant medical history of epilepsy and prior neurosurgery, he was dis…

neurologyemergency medicinediagnosticdelayparacetamol/codeine
WAhome2019-06-12

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

13y · Male·Epileptic seizure with aspiration

Child L, a 13-year-old boy with autism, cognitive impairment and poorly controlled generalised epilepsy, died from sudden unexpected death in epilepsy (SUDEP) with aspiration. His seizures remained refractory despite app…

neurologypaediatricsmedicationcommunicationlevetiracetam

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