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SA2003-11-07

Coroner's Finding: GOLDSMITH Brenton Maurice

19y · Male·Head injury: depressed stellate (star-shaped) fracture of skull with diffuse sub…

A 19-year-old male died from severe head injury (depressed stellate skull fracture with subarachnoid haemorrhage) sustained when a stolen motorcycle he was riding struck a kerb while evading police on Port Road, Adelaide…

emergency medicinetrauma surgerycommunicationsystemalcohol
SA2003-11-06

Coroner's Finding: AITKEN Lauren Kady and AITKEN Callum Macdonald

Lauren Kady Aitken: severe cerebral trauma associated with extensive cranial vau…

This is not a medical case. Two children (aged 12 and 10) died in a motor vehicle accident on 9 January 2000 when their father's vehicle left the roadway and fell 26 metres down an embankment near Crafers, South Australi…

SAhospital2003-11-05

Coroner's Finding: MARTIN Julie Anne

38y · Female·peritonitis with septic shock secondary to perforation of the gastrointestinal t…

A 38-year-old woman in persistent vegetative state following anoxic encephalopathy from anaphylaxis during surgery died from peritonitis caused by perforation at the gastrostomy stoma site. The perforation likely occurre…

anaesthesiaemergency medicinediagnosticcommunicationsuxamethonium
WAcommunity2003-10-31

Inquest into the Deaths of Noel James Monson and Robert Stephen McGee

Male·Multiple injuries from motorcycle collision with limestone retaining wall at rou…

Two motorcyclists, Noel James Monson (age 43) and Robert Stephen McGee (age 23), died following single-vehicle collisions at suburban roundabouts in Western Australia. Both riders lost control while approaching roundabou…

alcohol
SAcommunity2003-10-29

Coroner's Finding: NICHOLLS Geoffrey Douglas

41y · Male·Shotgun wound to the left side of the chest with laceration of the heart and hae…

Geoffrey Douglas Nicholls, aged 41, was shot by police during an armed incident at Oodnadatta, South Australia. He had a history of mental illness including depression with suicidal ideation, Bartter's syndrome (causing …

emergency medicinepsychiatrysystemdelay
SA2003-09-25

Coroner's Finding: GOROSTIAGA Jessica

8y · Female·Closed head injury

An 8-year-old girl died from severe closed head injuries sustained when a bouncy castle (inflatable amusement structure) was lifted by a sudden whirlwind and collapsed. The child fell from the structure during its flight…

systemprocedural
SAhospital2003-09-18

Coroner's Finding: NEWTON Ronald Luke

7y · Male·Hypoxic-ischaemic encephalopathy due to reflex cardiac arrest triggered by blunt…

A 7-year-old boy died from hypoxic-ischaemic encephalopathy following a motor vehicle collision. He was seated on an unanchored booster seat and wearing an adult seatbelt. During the collision, the unsecured booster seat…

intensive careemergency medicinesystem
NTcommunity2003-09-05

Inquest into the death of Mark Corbett

48y · Male·Acute cardiac dysrhythmia of unknown cause; acute alcohol toxicity was a signifi…

Mark Corbett, a 48-year-old Aboriginal man, died from acute cardiac dysrhythmia while in police protective custody in Tennant Creek. He was apprehended twice for public intoxication on 10 July 2002. After leaving a sober…

emergency medicineanaesthesiacommunicationsystemalcohol
VICcommunity2003-08-19

Nguyen Cindy

2y · Female·irreversible cerebral anoxia and terminal inhalation bronchopneumonia resulting …

Cindy Nguyen, a 2-year-old girl, drowned at Footscray Swimming Centre on 10 November 2000 and died from irreversible cerebral anoxia and inhalation bronchopneumonia on 15 November 2000. The coroner found that the death r…

emergency medicineparamedicinesystemcommunication
WAhospital2003-08

Inquest into the Death of Richard Christopher Jankowski

39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…

Richard Christopher Jankowski, a 39-year-old man, died from hypoxic brain injury due to respiratory obstruction following emergency surgery for a dental abscess with cellulitis. After initial treatment with antibiotics, …

anaesthesiageneral surgeryproceduralcommunicationpropofol
NTcommunity2003-07-31

Inquest into the death of Annette Kunia

29y · Female·severed spinal cord between the first and second cervical vertebrae sustained wh…

29-year-old Aboriginal woman died when thrown from a vehicle during a police pursuit that lasted 3-4 minutes over 9.2 km on Alice Springs Airport Road. She suffered a severed spinal cord between C1-C2 vertebrae, consiste…

communicationsystemalcohol
NThome2003-07-31

Inquest into the death of Queenie Michaels

11y · Female·pneumonia complicating cytomegalovirus embryopathy

Queenie Michaels, an 11-year-old Aboriginal girl with cytomegalovirus embryopathy and severe physical and cognitive disabilities, died from pneumonia at home while in government care. She had been fostered by Mr and Mrs …

paediatricsneurologyanti-convulsants
VIC2003-07-31

Pettet & Guajardo

Unknown·Multiple injuries from motor vehicle collision due to loss of control of tanker …

On 26 January 2001, five people died when a petrol tanker driven by Ranjith Naranpanawa lost control on the South Gippsland Highway near Koo Wee Rup, Victoria. The tanker collided with two oncoming vehicles carrying the …

systemdelay
SA2003-07-24

Coroner's Finding: Whyalla Airlines

21y·Double engine failure and ditching. Primary causes: left engine crankshaft fract…

On 31 May 2000, Piper Navajo Chieftain VH-MZK ditched in Spencer Gulf after two engine failures, killing seven passengers and the pilot, with one person missing. The coroner found that the right engine was damaged by end…

aviation medicinesystemprocedural
NThospital2003-07-17

Inquest into the death of Lennie Pinawrut

67y · Male·acute renal failure with associated severe acidosis and hyperkalemia

A 67-year-old Aboriginal male with dementia was discharged from Royal Darwin Hospital on 4 November 2001 following cystoscopy and bladder neck incision for suspected obstruction. Critical communication failures meant the…

urologysurgerycommunicationdelaygentamicine
VIChospital2003-06-29

Finding into death of Mohammed Tartourssi

3y · Male·unascertained

Mohammed Tartoussi, aged 3 years 11 months, presented to Bell Street Family Medical Centre on 28 June 2003 with chest pain and mild upper respiratory symptoms. He was diagnosed with mild symptoms and given prednisolone. …

emergency medicinepaediatricsdiagnosticsystemsalbutamol
WA2003-06-06

Inquest into the Death of Phillip Reginald James Steel

43y · Male·Multiple injuries from fall

Phillip Reginald James Steel, aged 43, a machinery operator at Mt Keith Nickel Mine in Western Australia, died on 18 May 2001 when the D10 bulldozer he was operating fell over 100 metres into an open pit. He was working …

communicationsystem
SAcommunity2003-05-27

Coroner's Finding: GILLIES Wayne John

45y · Male·Bullet wound to the head - self-inflicted

A 45-year-old man with recurrent major depression died by self-inflicted gunshot wound in April 2000. His psychiatrists documented recent suicidal ideation and unstable mental state but determined he was not actively sui…

psychiatrygeneral practicecommunicationsystemvenlafaxine
VICcommunity2003-05-21

DACK Lindsay

43y · Male·Drowning

Lindsay Dack, aged 43, drowned on 26 December 2000 while crewing the yacht Spirit of Downunder in the Big Bay Race 2000 in Port Phillip Bay. He was thrown overboard during a sudden squall while working on the foredeck, w…

systemprocedural
SAhospital2003-05-08

Coroner's Finding: PRATT Shirley May

66y · Female·acute necrotising haemorrhagic mediastinitis

Mrs Pratt, aged 66, underwent elective gastroscopy at Kapunda Hospital. During the procedure she heaved, and blood was noted at the gastro-oesophageal junction. She was discharged the same afternoon with pain, only to re…

surgerygeneral surgerycommunicationsystemfentanyl

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