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VICcommunity2016-06-01

Finding into death of Benjamin Albert Appelman

30y · Male·Mixed drug toxicity (methadone, amitriptyline, alprazolam, diazepam, oxazepam, n…

Benjamin Appelman, 30, died from mixed drug toxicity in a creek in December 2010. He had engaged in prescription shopping across multiple GPs and pharmacies to obtain benzodiazepines, obtaining 1050 alprazolam, 1540 diaz…

general practicetoxicologydiagnosticmedicationmethadone
VICmental health2016-06-01

Finding into death of Daniel John Woodburn

22y · Male·Multiple injuries secondary to fall from a height

Daniel Woodburn, a 22-year-old with first-episode psychosis presenting with command hallucinations, paranoia and depressed mood, was admitted as a voluntary patient to an unlocked inpatient unit at Orygen Youth Health on…

psychiatryemergency medicinecommunicationsystemdiazepam
VIChospital2016-05-30

Finding into death of Audrey Florence Eleanor Ebbage

1y · Female·Dilated cardiomyopathy

An 18-month-old girl died from dilated cardiomyopathy masquerading as croup. While initially misdiagnosed as croup was reasonable, the failure to reassess when clinical improvement did not occur was critical. Key failure…

paediatricsemergency medicinediagnosticcommunication
VIChospital2016-05-26

Finding into death of Delta Diawo Poke

42y · Female·Global cerebral ischaemia in a setting of anaesthesia

A 42-year-old woman died from global cerebral ischaemia following cardiac arrest during anaesthesia for a late-term termination of pregnancy. The anaesthetist, Dr McAllister, failed to obtain or ensure a functioning puls…

anaesthesiaobstetricsdiagnosticmedicationpropofol
VIChome2016-05-25

Finding into death of Sarah Louise Cafferkey

22y · Female·multiple stab injuries

Steven James Hunter, a serious violent offender with a prior 1988 murder conviction, was released on parole on 30 April 2011. During his parole, critical information about his unchanged violent attitudes, lack of empathy…

forensic medicinepsychiatrycommunicationsystemmethamphetamine
SAhospital2016-05-25

Coroner's Finding: PALTRIDGE Mellanie Joanne

25y · Female·ruptured splenic artery aneurysm with haemorrhage and internal blood loss

A 25-year-old pregnant woman (23 weeks) presented to hospital with sudden left upper quadrant abdominal pain and loss of consciousness. Clinical assessment identified renal colic and gallstones as likely diagnoses. She r…

obstetricsemergency medicinediagnosticdelayparacetamol
TAScommunity2016-05-25

Coroner's Finding: Barnes, Deearne Joan

53y · Female·mixed prescription drug toxicity

Deearne Joan Barnes, a 53-year-old woman with complex psychiatric history including depression, OCD, substance abuse disorder, and chronic non-cancer pain, died from mixed prescription drug toxicity involving venlafaxine…

psychiatrypain medicinediagnosticmedicationvenlafaxine
WAhospital2016-05-20

Inquest into the death of Sebastian Keith PARMAN

6y · Male·pneumonia complicating influenza A (H1N1) infection with secondary streptococcal…

Sebastian Parman, a 6-year-old boy, died from pneumonia complicating influenza H1N1 with secondary group A streptococcal infection causing scarlet fever, empyema and sepsis. Multiple clinical failures contributed: an inf…

emergency medicinepaediatricsdiagnosticcommunicationpenicillin
SAhospital2016-05-19

Coroner's Finding: WILLIAMS Jeremy Todd and CAMPBELL Robert

Male·neck compression due to hanging

Two men died by suicide within five months of emergency department assessments at Lyell McEwin Hospital. Both had been brought in by police under Mental Health Act section 57 but were not detained and discharged after mi…

emergency medicinepsychiatrydiagnosticcommunicationcitalopram
VICmental health2016-05-13

Finding into death of Shaun Luke Beagley

33y · Male·Mixed drug toxicity

Shaun Beagley, aged 33, died from mixed drug toxicity (heroin, methylamphetamine, benzodiazepines) while on overnight leave from E-PARCS psychiatric residential facility. He had been admitted following suicide attempts a…

psychiatryassessmentcommunicationheroin
VIChospital2016-05-12

Finding into death of Kevin Stanley Margetts

63y · Male·Bowel obstruction

A 63-year-old man with severe intellectual disability, quadriplegia, and blindness died from bowel obstruction with sepsis. On 5 September 2015, carers noted cough and eating difficulties. A locum doctor visited, noted h…

general practiceemergency medicinedelaysodium citrate enema
QLDhospital2016-05-06

Sweet, Lilli

6y · Female·Brain stem herniation due to pneumococcal meningitis

Lilli Sweet, a 6-year-old asplenic child with hereditary spherocytosis, died from pneumococcal meningitis with brain stem herniation. She presented to Nambour Hospital ED with vomiting, diarrhea, and headache on 25 Augus…

paediatricsemergency medicinediagnosticcommunicationparacetamol
SAhospital2016-05-05

Coroner's Finding: FALKENBERG Malcolm David

77y · Male·septic shock due to cellulitis of the left forearm

Malcolm Falkenberg, a 77-year-old man with dementia, died from septic shock due to cellulitis of the left forearm. He had been living independently with declining self-care and hygiene. Following a guardianship order, he…

geriatric medicineemergency medicinediagnosticdelayantibiotics
QLDhome2016-05-03

Zimmer, Laval Donovan

33y · Male·gunshot wound to the chest

A 33-year-old man with schizophrenia and epilepsy died from a gunshot wound after police were dispatched to his residence in response to repeated nuisance calls to emergency services. He had been tasered and arrested ear…

psychiatryemergency medicinesystemcommunication
QLDcommunity2016-05-03

Foster, Troy Martin

32y · Male·gunshot wounds to the trunk

Troy Martin Foster, a 32-year-old man with intellectual impairment, mild cognitive disability, and a history of substance abuse and violence, died following a police shooting. On 24 November 2014, he was detained under a…

psychiatryemergency medicinecommunicationsystemalcohol
VIC2016-04-29

Finding into death of Jack Glen Irvine

15y · Male·Global ischaemic brain injury post cardiac arrest secondary to anaphylaxis

Jack Glen Irvine, a 15-year-old with documented severe nut allergies and asthma, died from anaphylaxis triggered by consuming a macadamia nut cookie at a Victorian Karting Association camp. The cookie was provided despit…

emergency medicineintensive caresystemcommunicationadrenaline
VIChome2016-04-21

Finding into death of Kelly Ann Thompson

43y · Female·Stab wounds to the chest

Kelly Thompson was fatally stabbed by her estranged partner Wayne Wood on 9 February 2014 after he forcibly entered her home. Over 39 days from initial police contact on 1 January 2014, multiple system failures contribut…

psychiatrygeneral practicediagnosticcommunicationfluoxetine
TAScommunity2016-04-21

Coroner's Finding: Newett, Margaret Wynne

77y · Female·combined effects of ischaemic heart disease and calcific aortic valve sclerosis

Margaret Wynne Newett, 77, had moderate aortic stenosis diagnosed in 2011 but was never monitored with follow-up echocardiography as guidelines recommend. On 30 December 2013, she collapsed in a supermarket. At West Coas…

cardiologygeneral practicediagnosticcommunication
VICmental health2016-04-20

Finding into death of Chris Pravin Prasad

51y · Male·undetermined natural causes

Chris Prasad, a 51-year-old involuntary psychiatric inpatient with schizoaffective disorder, diabetes type 2, hypertension, and obesity (BMI 30.8), was granted day leave on 17 January 2013 during extreme heat (38°C) at C…

psychiatrygeneral medicinemedicationdiagnosticpaliperidone
QLDcommunity2016-04-20

Newport, Glenn Richard

38y · Male·cardiac arrest precipitated by dilutional hyponatraemia

A 38-year-old construction worker died from dilutional hyponatraemia after working in extreme heat (>40°C) on a concrete formwork project in rural Queensland. He developed symptoms of heat injury at the worksite and was …

occupational and environmental healthparamedicinediagnosticcommunication

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