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VICcommunity2017-10-24

Finding into death of Glenn Albert Sanders

48y · Male·Injuries sustained in an explosion

Glenn Sanders died from injuries sustained in explosions on his property during a police siege. Sanders had severe mental illness (Delusional Disorder/Schizophrenia), polysubstance abuse, and had rigged his house and far…

psychiatrygeneral practicecommunicationsystemrisperidone
QLDhospital2017-10-23

Non Inquest Findings TO

73y · Male·Sepsis (gram-negative septic shock) secondary to complications of selective inte…

A 73-year-old man died from gram-negative septic shock following selective internal radiation therapy (SIRT) for metastatic gastric cancer. He had previously undergone a Whipple procedure in 2014, which creates a direct …

radiologyemergency medicinediagnosticmedication
QLD2017-10-20

Anthony William Young, Shaun Basil Kumeroa, Edward Wayne Logan, Laval Donovan Zimmer and Troy Martin Foster

Male·Police use of lethal force; coroner found in each case the officers acted approp…

This multi-death inquest examined five police shootings in Queensland (2013-2014) where all deceased had mental health histories. The coroner found officers acted appropriately in each case but made 19 recommendations to…

emergency medicinepsychiatrysystemcommunicationmethamphetamine
NSWcommunity2017-10-17

Inquest into the death of Ashley Newton Bryant

44y · Male·Multiple traumatic injuries sustained in a fall from height

Ashley Bryant, a 44-year-old former NSW police officer with 24 years service, died by suicide at Minyon Falls on 16 December 2013 while suffering from PTSD, depression and alcohol dependence. The coroner found these cond…

psychiatryoccupational and environmental healthdiagnosticcommunicationtemazepam
NSWhome2017-10-13

Inquest into the death of D T

13y · Male·Self-inflicted (manner recorded as intentionally self-inflicted; specific method…

A 13-year-old boy with depression, migraine, school refusal and family instability died by intentional self-inflicted means. His general practitioner provided inadequate mental health assessment, initiated antidepressant…

general practicepsychiatrydiagnosticcommunicationfluoxetine
QLDhospital2017-10-06

Parsons, Ann

59y · Female·Global cerebral oedema due to hypoxic cerebral ischaemia following cardiac arres…

59-year-old woman admitted with newly diagnosed grade 4 glioblastoma underwent surgery 16 days later after delays during consultant's planned leave. Post-operative complications included ischaemic stroke confirmed on ima…

neurosurgeryintensive carediagnosticcommunicationdexamethasone
WAhospital2017-09-29

Inquest into the Death of Jared Charles OLSEN

41y · Male·Fulminant sepsis (Klebsiella pneumoniae) with multi-organ failure complicating s…

A 41-year-old man with newly diagnosed severe Crohn's colitis was prescribed 6-mercaptopurine (6-MP) after only 5 days of hospital treatment. He had a homozygous TPMT gene deficiency (present in ~0.3% of population) that…

gastroenterologyintensive carediagnosticsystem6-mercaptopurine
TAShospital2017-09-22

Coroner's Finding: Hosking, Jason Mathew Henry

34y · Male·Staphylococcus aureus sepsis and endocarditis

Jason Hosking, 34, presented to ED with vomiting, diarrhoea, fever, tachycardia and hypotension on 10 November 2014. Blood tests by 11.23am showed markedly elevated inflammatory markers (CRP 234.3, neutrophils 10.8, elev…

emergency medicinemicrobiologydiagnosticcommunicationoxycodone
VIChome2017-09-21

Finding into death of ALJW

21y · Male·Combined effects of heroin toxicity and plastic bag asphyxia

A 21-year-old man with complex congenital heart disease (Fontan procedure) died from combined heroin toxicity and plastic bag asphyxia. He had a history of depression and suicidality since childhood. In August 2014, duri…

cardiologypsychologycommunicationsystemheroin
QLDhospital2017-09-20

Mrs R-W - Non-inquest findings

83y · Female·Hyponatraemic encephalopathy due to adverse effects of citaprolam and duloxetine…

An 83-year-old woman with pre-existing SIADH-related chronic hyponatraemia died from hyponatraemic encephalopathy following antidepressant therapy. Critical clinical lessons include: (1) the importance of accessing prior…

general medicineemergency medicinediagnosticmedicationcitalopram
QLDaged care2017-09-20

Mr RO'H - Non-inquest findings

69y · Male·septic shock due to infected decubitus ulcers complicated by osteomyelitis

A 69-year-old man with Parkinson's disease died from septic shock caused by infected pressure ulcers (stage 4 decubitus ulcers with osteomyelitis) that developed in aged care. Pressure sores appeared within 31 days of ad…

geriatric medicinegeneral practicediagnosticsystemdicloxacillin
WAhome2017-09-15

Inquest into the Death of Mary Josephine Van der WALT

28y · Female·ligature compression of the neck

Mary Van Der Walt, a 28-year-old with depression, anxiety, and borderline personality disorder, died by hanging on 21 April 2014. Two police officers responding to her initial '000' call found her unresponsive and pulsel…

emergency medicineintensive carediagnosticcommunicationdesvenlafaxine
QLDcommunity2017-09-14

John, Timothy

22y · Male·Hanging

Timothy John, age 22, died by hanging 8 days after commencing varenicline (Champix) for smoking cessation. He had a documented history of depression, anxiety, and substance abuse, with prior attempted suicide. His GP, Dr…

general practicepsychiatrydiagnosticcommunicationvarenicline
ACThome2017-09-11

AN INQUEST INTO THE DEATH OF LESLEY MAREE SMITH

47y · Female·Sudden Unexpected Death in Alcohol Misuse (SUDAM)

Lesley Maree Smith, 47, died at home on 9 May 2013 from Sudden Unexpected Death in Alcohol Misuse (SUDAM). She had chronic alcohol misuse (2 bottles nightly) and was prescribed diazepam by her GP, Dr H., starting April 2…

general practicepathologydiagnosticcommunicationdiazepam
QLDhospital2017-09-02

ML - Non-inquest findings

71y · Female·Haemothorax and haemopericardium secondary to ruptured dissecting aneurysm of th…

A 71-year-old woman with hypertension and prior myocardial infarction presented to emergency with sudden chest pain, jaw pain, and syncope. Aortic dissection was appropriately suspected and a contrast CT-aortagram was pe…

emergency medicinecardiologydiagnosticsystemintravenous fluids
NSW2017-08-31

Inquest into the death of David WOTHERSPOON

31y · Male·Hypoxic encephalopathy caused by neck compression due to hanging

David Wotherspoon, a 31-year-old Aboriginal man with schizophrenia, died from hypoxic encephalopathy following hanging in a prison mental health unit. Despite being psychotic and refusing medication, he was not transferr…

psychiatrycorrectional healthsystemcommunicationrisperidone
VIChome2017-08-28

Finding into death of Tara Sue Love

22y · Female·Sudden Arrhythmic Death Syndrome

Tara Love, a 22-year-old woman, died from sudden arrhythmic death syndrome due to long QT syndrome (LQTS). She presented multiple times to the Royal Women's Hospital with ECG changes and electrolyte abnormalities during …

obstetricscardiologydiagnosticcommunicationlabetalol
VICcommunity2017-08-25

Finding into death of Thomas Edward Mackenzie Hall

41y · Male·Injuries sustained in a motor vehicle incident (driver) in a man with coronary a…

Thomas Hall, a 41-year-old man with schizophrenia and coronary atherosclerosis, died in a head-on motor vehicle collision after driving his mother's car unlicensed and at excessive speed into oncoming traffic. He had a d…

psychiatryemergency medicinecommunicationsystemrisperidone
WAhospital2017-08-23

Inquest into the Death of Marjorie Joy JARICK

54y · Female·Opioid toxicity (predominantly fentanyl)

54-year-old woman with diabetes, obesity, and multiple opioid allergies underwent groin surgery at a private hospital. Anaesthetist Dr Y. prescribed a 75mcg/hr fentanyl patch post-operatively for chronic pain management …

anaesthesiasurgerymedicationcommunicationfentanyl
TAShospital2017-08-22

Coroner's Finding: AH - de-identified

37y · Female·asphyxia due to hanging

A 37-year-old woman with major depression and Crohn's disease was admitted to hospital following a suicide attempt. She was discharged after less than two days following clinical improvement, against her husband's reserv…

psychiatryemergency medicinediagnosticcommunicationescitalopram

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