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NSWhome2016-09-14

Inquest into the death of NA

0y · Male·Hypoxic ischaemic encephalopathy (brain damage) sustained during and just after …

A newborn died from hypoxic-ischaemic encephalopathy following a home birth without medical assistance. The mother had significant risk factors: hepatitis C, anaemia, and transverse fetal lie confirmed at 38+ weeks gesta…

general practiceobstetricscommunicationsystem
NSW2016-09-12

Inquest into the death of M

15y · Female·hypoxic brain damage due to multiple drug toxicity

A 15-year-old girl in out-of-home residential care died from accidental overdose of heroin and methylamphetamine (speedballing) in her bedroom while a known drug user was present. She had complex trauma from childhood ab…

emergency medicinetoxicologydelaysystemheroin
WAhospital2016-09-08

Inquest into the Death of Anandakumar SELLAKATHIRKGAMAN

38y · Male·hypoxic brain injury and organ failure following compression of the neck (hangin…

A 38-year-old Sri Lankan asylum seeker died by suicide after being released from immigration detention on a bridging visa. He had documented anxiety and trauma history during detention, managed by psychiatrist Dr A. who …

psychiatryemergency medicinediagnosticcommunicationdiazepam
NSWmental health2016-09-07

Inquest into the death of Miriam MERTEN

Female·traumatic and hypoxic brain injury caused by numerous falls and self-beating of …

Miriam Merten died from traumatic and hypoxic brain injury sustained during 25+ falls while in seclusion in a mental health unit. Critical clinical failures occurred: she was not provided one-to-one observation during th…

psychiatrycommunicationproceduralpsychotropic medications
VICcommunity2016-09-06

Finding into death of Antonio D'Augello

63y · Male·Drowning

Antonio D'Augello, a 63-year-old man with schizophrenia and acquired brain injury, died by drowning in an irrigation channel four days after discharge from emergency care. He had deteriorated after stopping antipsychotic…

psychiatryemergency medicinecommunicationdelayolanzapine
VIChome2016-09-05

Finding into death of Cathy Mary McPhee

58y · Female·Stab wounds to chest

A 58-year-old woman died from stab wounds inflicted by her husband during a domestic violence incident. The marriage had been deteriorating with documented controlling and abusive behaviour including isolating her from f…

psychologyforensic medicinecommunicationalcohol
QLDhospital2016-09-02

Calder, Michael James

33y · Male·Opiate toxicity

A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both slow-release (MS Co…

general medicineemergency medicinemedicationdiagnosticmorphine
NThospital2016-09-01

Inquest into the death of Kerry James Murphy

73y · Male·Acute subdural haematoma

Kerry James Murphy, 73, died from acute subdural haematoma following a fall in Royal Darwin Hospital's overcrowded Emergency Department. He was admitted with pneumonia, NSTEMI, and dizziness—significant fall risk factors…

emergency medicinecardiologysystemcommunicationblood thinners
NSWcommunity2016-08-26

Inquest into the death of Stacy Lee HUTCHINS

25y · Female·head injury sustained when she fell from a moving truck

Stacey Lee Hutchins, 25 years old, died from severe head injuries sustained when she fell from a moving truck driven by her former partner, Dean Willett, on 5 June 2007. The death followed her abduction at knifepoint by …

communicationsystem
WAcommunityPodcast2016-08-22

Inquest into the Death of Ewan Louis WILLIAMSON

14y · Male·severe heatstroke complicating a recent viral illness with focal myocarditis

A 14-year-old boy from Scotland died of severe heatstroke with myocarditis while hiking in extreme heat (40°C+) at Cape Range National Park. He had recently recovered from a viral illness. His father made navigation erro…

emergency medicineparamedicinecommunicationdelay
VIChospital2016-08-22

Finding into death of Alison Rae Wolinski

36y · Female·Hanging

A 36-year-old woman with borderline personality disorder and alcohol use disorder died by hanging approximately one month after discharge from St Vincent's Hospital. She had been admitted involuntarily following threats …

psychiatryemergency medicinecommunicationsystemvenlafaxine
VIChome2016-08-19

Finding into death of Anthony John Toscano

45y · Male·small bowel obstruction due to plastic bag bezoar

Anthony Toscano, a 45-year-old man with intellectual disability residing in supported accommodation, died from small bowel obstruction caused by a plastic bag bezoar. He presented with vomiting on 20 August 2015 and was …

general practiceforensic medicinediagnosticdiazepam
QLDhospital2016-08-19

Plumb, Mark Anthony

76y · Male·Multiple organ failure due to sepsis with peritonitis and pancreatitis, secondar…

A 76-year-old man died from multiple organ failure following an ERCP procedure for gallstone removal. The procedure itself was appropriate and uneventful. Post-operatively, he developed severe abdominal pain and a CT sca…

surgeryanaesthesiadiagnosticcommunicationmorphine
SAaged care2016-08-19

Coroner's Finding: CLAYTON James Edmund

59y · Male·ischaemic heart disease due to coronary atherosclerosis; acute myocardial infarc…

A 59-year-old man with ischaemic heart disease, paranoid schizophrenia, unstable type 2 diabetes, peripheral vascular disease and chronic renal failure died of acute myocardial infarction while residing in aged care. He …

cardiologypsychiatrydiagnosticdelay
VICcommunity2016-08-18

Finding into death of Paul Daniel Rayudu

22y · Male·hypoxic ischaemic encephalopathy in the setting of immersion (drowning)

Paul, a 22-year-old with limited swimming experience, drowned at WaterMarc public pool on 2 February 2014 in a crowded busy period. The 50-metre pool was being divided by a movable boom, which two lifeguards were returni…

communicationsystem
NSWcommunity2016-08-11

Inquest into the death of Afif Fakhouri

37y · Male·Combination of methylamphetamine toxicity and restraint leading to physiological…

A 37-year-old man died after being physically removed and restrained by NSW TrainLink staff at Cootamundra Station. He was displaying erratic, agitated behaviour consistent with methylamphetamine intoxication and possibl…

emergency medicineforensic medicineproceduralcommunicationmethamphetamine
ACTaged care2016-08-10

AN INQUEST INTO THE DEATH OFCHARLES ROWAN McCULLOCH

94y · Male·blunt head and neck trauma with associated haemorrhage; neck trauma included fra…

Charles Rowan McCulloch, aged 94, died from blunt head and neck trauma sustained in an assault by another dementia resident in Jindalee Aged Care Residence, ACT. He was admitted on 20 January 2012 and found deceased on 2…

geriatric medicineemergency medicinediagnosticcommunicationrisperidone
TAShospital2016-08-08

Coroner's Finding: Teressa Beswick

45y · Female·Combined effects of widely metastatic (end-stage) carcinoma of the cervix and br…

Teressa Maree Beswick, a 45-year-old woman with end-stage metastatic cervical cancer, died from the combined effects of her cancer and bronchopneumonia accelerated by a critical medication error. On 23 October 2014, she …

emergency medicinegeneral practicemedicationproceduralmorphine
QLDhospital2016-08-04

Clarke, David Michael

56y · Male·intra-abdominal haemorrhage due to splenic rupture due to blunt force injury to …

David Michael Clarke, aged 56, died from intra-abdominal haemorrhage due to splenic rupture following blunt force injury to his back. The fatal injury occurred after he was kicked by Jeffrey Zinn during a violent alterca…

emergency medicineintensive caresystemdelay
SAhospital2016-08-03

Coroner's Finding: LAMBROPOULOS Andrea

34y · Male·hypoxic-ischaemic encephalopathy following laparoscopic bariatric surgery with i…

Andrea Lambropoulos, a 34-year-old man with morbid obesity, sleep apnoea, and ischaemic heart disease, died following sleeve gastrectomy. He was admitted to HDU rather than ICU post-operatively. In HDU, he experienced re…

bariatric surgeryanaesthesiacommunicationdelaymorphine

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