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TAShome2018-02-28

Coroner's Finding: Evans, Jillian and John

62y · Male·Mr Evans: self-inflicted gunshot wound to head and asphyxiation by hanging. Mrs …

In September 2013, Mr John Evans (62) killed his wife Jillian after he experienced psychosis manifesting as delusions about chemical infestation of their home. The coroner found Mr Evans was psychotic at the time of deat…

psychiatrygeneral practicediagnosticcommunicationrisperidone
WA2018-02-28

Inquest into the Death of Mason Laurence CARTER and Murray Allan TURNER and Chad Alan FAIRLEY

57y · Male·immersion (drowning) - for Turner confirmed by post mortem; for Carter and Fairl…

Three fishermen died when the fishing vessel 'Returner' capsized in Nickol Bay, Western Australia on 11 July 2015. Murray Turner (57) owned and extensively modified the vessel; Chad Fairley and Mason Carter were deckhand…

occupational and environmental healthdiagnosticcommunication
WA2018-02-28

Inquest into the Death of Chad Alan FAIRLEY and Mason Laurence CARTER and Murray Allan TURNER

57y · Male·Immersion (drowning) for Murray Turner; likely immersion (drowning) for Mason Ca…

The fishing vessel Returner capsized in Nickol Bay on 11 July 2015, killing three men including experienced skipper Murray Turner (aged 57) and deckhands Chad Fairley (29) and Mason Carter (26). The vessel's catastrophic…

occupational and environmental healthdiagnosticcommunication
WA2018-02-28

Inquest into the Death of Murray Allan TURNER and Mason Laurence CARTER and Chad Alan FAIRLEY

Male·immersion (drowning) for Murray Turner; unascertained but likely immersion for C…

Three men died when the fishing vessel Returner capsized in Nickol Bay, Western Australia on 11 July 2015. The vessel had undergone extensive modifications by owner Murray Turner (age 57) without proper stability assessm…

occupational and environmental healthdiagnosticprocedural
NSWhospital2018-02-27

Inquest into the death of Michaela Perrin

26y · Female·sepsis

Michaela Perrin, 26, died from sepsis arising from a post-caesarean wound infection caused by MRSA on 22 October 2014. She presented to the Emergency Department on 20 October with severe pain, tachycardia (125 bpm), and …

obstetricsemergency medicinediagnosticcommunicationceftriaxone
NSWhome2018-02-23

Inquest into the death of Yongxing Wang

79y · Male·hypoxic brain injury due to cardio-respiratory arrest caused by opioid toxicity

Yongxing Wang, 79, died from hypoxic brain injury caused by opioid toxicity from combined morphine and oxycodone. After a minor back injury on 21 August, he received a cortisone injection on 22 August with complications.…

general practiceradiologymedicationcommunicationmorphine
QLDhospital2018-02-21

Barichello, Daniele Antony - Non-inquest findings

43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…

A 43-year-old man with a colloid cyst of the third ventricle presenting with progressive headache was admitted for planned endoscopic surgery. Surgery was delayed from Friday to Monday due to unavailability of specialist…

neurosurgeryintensive carediagnosticdelaytramadol
NSW2018-02-16

Inquest into the death of Carney Schultz

28y · Female·complications of epilepsy

Carney Schultz, a 28-year-old woman with severe cerebral palsy, hydrocephalus, and epilepsy, died on 21 April 2015 at a group home. She experienced a seizure around 3:20am managed by a disability support worker (DSW) wit…

neurologygeneral practicecommunicationsystemmidazolam
QLD2018-02-16

Cheney, Danny George

Male·Electrocution from electrical induction shock while installing spacers on high-v…

Danny George Cheney, a newly promoted Construction Manager and Stringing Supervisor with John Holland Group, died from electrocution while installing spacers on high-voltage transmission line conductors. Working from a c…

occupational and environmental healthdiagnosticprocedural
QLDmental health2018-02-05

Hitchins, Steven John; Gudge, Shawn Bradley Joseph

53y · Male·Steven Hitchins: plastic bag asphyxiation; Shawn Gudge: hanging

Two inpatient suicides in a Queensland mental health unit highlight systemic failures in environmental hazard management and observation practices. Steven Hitchins (age 53) died by asphyxiation with a plastic bag in 2014…

psychiatryemergency medicinesystemcommunicationrisperidone
NSWmental health2018-02-02

Inquest into the death of MA

28y · Male·Neck compression consistent with hanging

A 28-year-old man with severe depression, persistent suicidal ideation and previous suicide attempts died by hanging in a mental health inpatient unit while under involuntary detention. Despite being assessed as high sui…

psychiatrysystemcommunicationvenlafaxine
VICmental health2018-02-01

Finding into death of Joy Maree Guppy

59y · Female·Hypoxic ischaemic brain injury secondary to compression of the neck in the circu…

A 59-year-old woman with major depression died by hanging using her dressing gown tie while a voluntary inpatient at a private psychiatric clinic. She was assessed as low-risk and had no restriction on ligature access. D…

psychiatryemergency medicinesystemdiagnosticquetiapine
VIChome2018-02-01

Finding into death of Devlin Charles Duffy

21y · Male·asphyxia from inhalation of helium

21-year-old Devlin Duffy died from asphyxia due to helium inhalation. He had connective tissue disease causing chronic pain and disability. In May 2016, his GP Dr N. diagnosed moderate depression and prescribed desvenlaf…

general practicepsychiatrycommunicationsystemdesvenlafaxine
TASaged care2018-01-29

Coroner's Finding: Ball, Betty Irene

67y · Female·perforated sigmoid volvulus with peritonitis upon a background of spinocerebella…

Betty Irene Ball, aged 67, died from perforated sigmoid volvulus with peritonitis on 2 February 2016. She had spinocerebellar ataxia and was resident in aged care. She developed constipation from 15 January 2016, but med…

general practiceemergency medicinedelaysystemparacetamol
TAScommunity2018-01-25

Coroner's Finding: Lockwood, Shane

45y · Male·Stab wound to the chest, self-inflicted

Shane Lockwood, a 45-year-old man with chronic schizophrenia, died by self-inflicted stab wound in April 2009, approximately two months after discharge from psychiatric hospital on a Community Treatment Order. He was dis…

psychiatrygeneral practicecommunicationsystemclozapine
TAShospital2018-01-24

Coroner's Finding: Woolley, Paul James

50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngea…

A 50-year-old man died from pulmonary thromboembolism following uvulopalatopharyngoplasty (UPPP) surgery for obstructive sleep apnoea. Critical failures in post-operative management at a private hospital included: failur…

ENT surgeryanaesthesiacommunicationsystemmorphine
TAShospital2018-01-23

Coroner's Finding: Mr M

41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…

A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr R.'s failure to diagnose stroke on 7 September and arrange u…

emergency medicineneurologydiagnosticcommunication
SA2018-01-17

Coroner's Finding: COSTI John Steve

39y · Male·neck compression (due to hanging) and plastic bag asphyxia

John Steve Costi, aged 39, died by suicide in Adelaide Remand Centre on 27 November 2013. He fashioned a ligature from bedding strips and hanged himself using an unusual hanging point in his single cell between 4am and 6…

correctional healthpsychologysystemdelay
NThospital2018-01-11

Inquest into the death of Addison Anthony

35y · Male·Active rheumatic pancarditis complicated by pulmonary arterial hypertension, pne…

A 35-year-old Aboriginal man died from rheumatic pancarditis complicated by pulmonary hypertension, pneumonia and unspecified connective tissue disease. He had presented repeatedly to Katherine Hospital with symptoms sug…

emergency medicineintensive carecommunicationdiagnosticdicloxacillin
VICcommunity2018

Finding into death of Konstantinos Eleftheriou-Tragakis

36y · Male·Hanging

A 36-year-old man with schizoaffective disorder, substance use disorder, and previous psychotic episodes was discharged from psychiatric inpatient care after being absent without leave for 72 hours. On 4 June 2017, he co…

psychiatrycommunicationsystemrisperidone

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