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VIChospital2016-02-15

Finding into death of Mairi Elizabeth Noble

57y · Female·Injuries sustained when struck by a train

Mairi Elizabeth Noble, a 57-year-old woman with a history of alcoholism who achieved sobriety, presented to the Northern Hospital ED twice in the days before her death by suicide. She was discharged prematurely on 21 Feb…

emergency medicinepsychiatrycommunicationsystemmirtazapine
WAhome2016-02-10

Inquest into the Death of Adrian Marcus WESTLUND

22y · Male·Combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan and op…

Adrian Westlund, a 22-year-old with complex drug-seeking behaviour and polypharmacy addiction, died of combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan). He manipulated multiple GPs by misreprese…

general practiceaddiction medicinediagnosticcommunicationalprazolam
QLDhome2016-02-09

DM

35y · Female·Stab wound to chest penetrating the descending thoracic aorta resulting in catas…

DM, a 35-year-old woman, died from a stab wound to the chest inflicted by her husband during a domestic violence incident on 26 June 2011. The wound penetrated the descending thoracic aorta, causing catastrophic blood lo…

forensic medicineemergency medicinesystemcommunicationamphetamine
SAaged care2016-02-08

Coroner's Finding: FORD Marie Janet

84y · Female·acute left subdural haematoma

Marie Janet Ford, 84 years old with dementia, fell from a chair at a residential aged care facility and sustained an acute left subdural haematoma. She was on warfarin for deep vein thrombosis and atrial fibrillation. In…

geriatric medicineemergency medicinecommunicationsystemwarfarin
VICcommunity2016-02-05

Finding into death of Penelope Pratt

27y · Female·multiple gunshot injuries with a stab injury to the heart

Penelope Pratt, 27, was murdered on 28 November 2010 following discharge from a psychiatric admission at Maroondah Hospital. She called 000 twice that evening from an unsafe situation with armed individuals. The first ca…

emergency medicinepsychiatrycommunicationsystemamphetamine
QLDcommunity2016-02-05

Cooper, Paul James - Non-inquest findings

41y · Male·Hanging

Paul Cooper, a 41-year-old man with bipolar disorder, died by hanging in August 2015, eleven days after psychiatric review. He had recently commenced Isotretinoin for severe acne, which coincided with development of para…

psychiatrygeneral practicecommunicationsystemisotretinoin
NSWcommunity2016-01-29

Jimmy JAMES - Findings

44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)

Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…

emergency medicineintensive carediagnosticmedicationceftriaxone
SAhome2016-01-28

Coroner's Finding: NAPIER Ebony Simone

0y · Female·Blunt head trauma from multiple deliberate blows inflicted by father

Ebony Napier, aged 4 months, died from blunt head trauma resulting from multiple deliberate blows inflicted by her father Bradley Napier-Tucker over several weeks. A critical failure occurred when the South Australian ch…

paediatricsradiologydiagnosticcommunicationcannabis
VICcommunity2016-01-19

Finding into death of Benjamin Hodgson

29y · Male·Diabetic ketoacidosis

Benjamin Hodgson, a 29-year-old man, presented to his GP on 20 January 2014 with polyuria, polydipsia, difficulty sleeping, fever (38.6°C), and hypertension. The GP diagnosed a urinary tract infection and prescribed anti…

general practicepathologydiagnosticdelaycefalexin
QLDcommunity2016-01-15

Barclay, Matthew Stephen

14y · Male·Drowning

Matthew Barclay, 14, died during an under-15 board race at the 2012 Australian Surf Life Saving Championships at Kurrawa Beach. While competing, he became unconscious likely from impact with a dumping wave on shallow san…

emergency medicineoccupational and environmental healthsystemprocedural
VIChospital2016

Finding into death of Zakiya Crystal Lisa Thomas

15y · Female·Hanging

Zakiya, a 15-year-old Barkindji Maraura woman, died by hanging at Mildura Base Hospital following a family argument about repaying a borrowed $300. She had disclosed experiences of childhood sexual abuse by her uncle, ph…

psychiatrypaediatricscommunicationsystemcitalopram
VICcommunity2016

Finding into death of XY

58y · Male·Combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propra…

A 58-year-old man with chronic depression, anxiety and personality disorders died from combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propranolol, diazepam) after presenting to ED with suicidal…

psychiatryemergency medicinediagnosticcommunicationeucalyptus oil
VIChome2016

Finding into death of Sharon Denise Siermans

29y · Female·blunt head injuries

Sharon Denise Siermans, a 29-year-old mother, was murdered by Jason Dinsley in April 2013 while he was on parole. Dinsley had a long history of violent sexual offences and had tested positive to cannabis in March 2013, t…

forensic medicinecorrectional healthsystemdelaycannabis
WAmental health2015-12-31

Inquest into the Deaths Alma Street Centre

Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…

Five former psychiatric patients of Alma Street Centre (part of Fremantle Hospital) died between March 2011 and March 2012. Two died by suicide within 24 hours of discharge; one disappeared and was found deceased; one ab…

psychiatryemergency medicinediagnosticcommunicationantidepressants
WAmental health2015-12-31

Inquest into the Death of Anthony Ian EDWARDS

Female·Multiple causes: Ruby Natasha Nicholls-Diver: ligature compression of neck (hang…

Five psychiatric patients from Alma Street Centre (Fremantle Hospital) died by suicide within 12 months (March 2011-March 2012). Two died within 24 hours of discharge, demonstrating critical failures in mental health ser…

psychiatryemergency medicinediagnosticcommunicationantidepressants
WAmental health2015-12-31

Inquest into the Death of Carly Jean ELLIOTT

Unknown·Ruby: ligature compression of the neck (hanging); Carly: ligature compression of…

Five young to middle-aged people with serious mental health conditions died by suicide within 12 months (March 2011 to March 2012) while under care from Alma Street Centre mental health services in Western Australia. Rub…

psychiatryemergency medicinecommunicationsystemantidepressants
WAmental health2015-12-31

Inquest into the Death of Ruby Natasha NICHOLLS-DIVER

Multiple - hanging (2), unknown/unascertainable (1), multiple injuries from fall…

Five patients of Alma Street Centre's psychiatric unit died within 12 months (2011-2012). Three died by suicide within 24 hours of discharge; one disappeared and died; one absconded while detained and died. Clinical less…

psychiatryemergency medicinecommunicationdiagnosticantidepressants
WAmental health2015-12-31

Inquest into the Death of Stephen Colin ROBSON

Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…

Five psychiatric patients of Alma Street Centre died between March 2011 and March 2012. Two (Ruby Nicholls-Diver and Anthony Edwards) died within 24 hours of discharge; two (Carly Elliott and Michael Thomas) died shortly…

psychiatryemergency medicinediagnosticcommunicationclozapine
WAmental health2015-12-31

Inquest into the Death of Michael Ronald THOMAS

Unknown·Ruby: ligature compression of neck (hanging); Carly: ligature compression of nec…

Five young adults died by suicide within 12 months (March 2011 to March 2012), all connected to Alma Street Centre mental health services at Fremantle Hospital. Four were discharged (Ruby Nicholls-Diver, Carly Elliott, M…

psychiatryemergency medicinediagnosticcommunicationantidepressants
TAScommunity2015-12-23

Coroner's Finding: Field, Jayden Craig

19y · Male·Severe traumatic head injury sustained from impact with roadway surface after ex…

Jayden Craig Field, a 19-year-old intoxicated male, died from severe traumatic head injury sustained when he exited a moving taxi at approximately 41-48 km/h after a planned fare evasion. The coroner found that all four …

emergency medicinetrauma surgerydelaysystemalcohol

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