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NT2001-10-10

Inquest into the death of Skeletal Remains (Cartier Island)

30y · Male·unknown - unable to determine due to advanced decomposition

An unidentified male of Asian origin, aged 25-35 years, died at sea approximately seven miles off Cartier Island in March 2000 after becoming ill while diving for trepang at about 30 metres depth. The cause of death coul…

forensic medicinedentistry
SAcommunity2001-10-05

Coroner's Finding: BEDNAREK Shantel Lisa

7y · Female·Multiple abdominal injuries including traumatic rupture of the liver and stomach…

A 7-year-old girl died from massive abdominal injuries sustained when a car, driven by an insulin-dependent diabetic man, collided with a group of pedestrians. The driver had undiagnosed and unaware hypoglycemia at the t…

endocrinologyemergency medicinediagnosticcommunicationinsulin
VIC2001-09-19

Gisborne Aircraft Crash

Multiple injuries from aircraft crash resulting from aerodynamic stall during st…

On 1 December 1999, a Cessna 172R aircraft piloted by 18-year-old Sean Bysouth crashed near Gisborne, Victoria, killing all four occupants: Bysouth, David Kemp (19), Glen Tisdale (21), and Jodie Thomas (17). The aircraft…

SAhome2001-09-10

Coroner's Finding: CORNISH Olive Edna

75y · Female·Avulsion of the inferior vena cava from the heart due to severe crush injury of …

A 75-year-old woman died from crush injuries sustained when her 1982 Mitsubishi Sigma sedan reversed unexpectedly whilst she was behind it. The vehicle's automatic transmission selector linkage had worn bushes, allowing …

SAhospital2001-09-07

Coroner's Finding: SANDS Celia Laurel

82y · Female·peritonitis due to a perforated viscus (proximal jejunum) resulting from motor v…

An 82-year-old woman suffered a motor vehicle accident causing blunt abdominal trauma. Despite initial clinical assessment appearing adequate, a perforated jejunum with developing peritonitis was not diagnosed until earl…

general surgeryemergency medicinediagnosticdelay
SAhospital2001-09-04

Coroner's Finding: CHESTER George Spencer

18y · Male·multiple injuries

George Spencer Chester, 18, died from multiple injuries sustained when a stolen Toyota 4WD he was driving rolled on Decres Bay Road after failing to negotiate a bend while being pursued by police. He was ejected from the…

emergency medicinetrauma surgery
SAcommunity2001-09-04

Coroner's Finding: COVENTRY James Steven Joseph

27y · Male·traumatic rupture of the mid brain complicating ring fracture of the skull base

James Steven Joseph Coventry, aged 27, died from traumatic rupture of the midbrain and ring fracture of the skull base after his vehicle collided with trees while evading police. The death was not due to police conduct; …

forensic medicinepsychiatrysystemcommunicationmethamphetamine
SAhome2001-08-28

Coroner's Finding: KERRISON Noel James

82y · Male·Carbon monoxide poisoning, contributing factor: ischaemic heart disease due to c…

An 82-year-old man died from carbon monoxide poisoning in his home. His gas cooker had a faulty regulator operating at 0.7 kPa instead of the required 1.0 kPa, causing excessive pressure drop when burners were activated.…

system
SAhospital2001-08-24

Coroner's Finding: GADALETA Saverio

28y · Male·Peritonitis and septic shock complicating perforation of the terminal small bowe…

A 28-year-old man with cerebral palsy, microcephaly, and epilepsy presented to the ED with abdominal pain, fever, and signs of deterioration. Triaged as Priority 3 despite these concerning features, he was not seen by a …

emergency medicinegeneral surgerycommunicationdelayparacetamol
SA2001-08-21

Coroner's Finding: IRVINE Samantha and SAKAMOTO Goro

26y · Male·Multiple injuries from mid-air aircraft collision

Two aircraft collided mid-air during gliding operations near Waikerie, South Australia. The Japanese glider pilot, Goro Sakamoto, failed to maintain adequate lookout and did not effectively use radio communication to ann…

communicationsystem
NT2001-08-17

Inquest into the death of Blake Harvey

0y · Male·Burns from fire

A six-month-old child died from burns after a fire started at a roadhouse accommodation when his older sibling (5 years old) ignited a portable gas cooker with a cigarette lighter. The cooker was accessible in the room d…

emergency medicineretrieval medicineproceduralsystem
VIC2001-08-09

NINE DEATHS

Unknown·Multiple injuries sustained in motor vehicle collision (head-on collision follow…

Nine deaths occurred in four separate crossover collisions on Victorian freeways between January and December 1999, when vehicles lost control, crossed median strips, and collided with oncoming traffic. The deceased were…

systemcitalopram
ACT2001-08

Inquest Into The Manner And Cause Of Death Of Brett Ponting

33y · Male·Cerebral hypoxia caused by drowning

A 33-year-old man with severe intellectual disability and cerebral palsy drowned in a bath at a supported accommodation house. Carers left him unattended in the bath despite an Individual Plan stating 'full assistance re…

geriatric medicineemergency medicinecommunicationsupervision
SAhome2001-07-16

Coroner's Finding: BRADY Mary

64y · Female·Haemorrhagic bronchopneumonia complicating doxepin overdosage

A 64-year-old woman died from doxepin overdose complicated by haemorrhagic bronchopneumonia. She had attempted suicide in April 1999 and was referred to a psychiatrist (Professor Schioldann) who prescribed sertraline. He…

general practicepsychiatrycommunicationmedicationdoxepin
SAhospital2001-07-13

Coroner's Finding: TRIMBOLI Jayden Tyler

0y · Male·hypoxic-ischaemic encephalopathy due to prolonged fetal bradycardia

Jayden Tyler Trimboli, aged 6 days, died from hypoxic-ischaemic encephalopathy caused by a prolonged fetal bradycardia episode between 11:10pm and 11:50pm on 18 September 1998. The critical failure was that the cardiotoc…

obstetricsmidwiferycommunicationsystemprostaglandin gel
SAcommunity2001-06-02

Coroner's Finding: MacLEOD Grant Alistair

38y · Male·Internal haemorrhage complicating large calibre gunshot wounds to the neck

Grant MacLeod, aged 38, died from a gunshot wound to the neck inflicted by Constable Mark Buckingham during a police response to reports of an armed person at a service station. MacLeod had suffered severe head injury in…

psychiatryforensic medicinesertraline
NTcommunity2001-05-23

Inquest into the death of Corey Leigh McConville

25y · Male·Multiple injuries from motor vehicle accident (road train rollover)

A 25-year-old road train driver fell asleep at the wheel on the Victoria Highway, causing a fatal rollover accident. Over nine days before his death, he worked multiple long-haul shifts with minimal rest, achieving fatig…

occupational and environmental healthsystemdelay
SAhospital2001-05-16

Coroner's Finding: KLOSE Glen Malcolm

71y · Male·Saddle pulmonary embolus as a consequence of deep venous thrombosis in the right…

Glen Malcolm Klose, aged 71, died from a saddle pulmonary embolus secondary to deep vein thrombosis in his right calf, a complication associated with his history of multiple knee surgeries. He was admitted to Glenside Ho…

psychiatrygeneral medicinedelay
SAhospital2001-05-04

Coroner's Finding: ROACH Dawn Ruth

45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…

A 45-year-old woman died from multi-organ failure following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (1.5 cm) was contained and re…

colorectal surgerygeneral surgeryproceduralcommunication
WAhospital2001-04-12

Inquest into the Death of Margaret Patton Brooks

43y · Female·Haemorrhage Associated with Penetrations of the Aorta

Margaret Brooks, a 43-year-old woman, died from haemorrhage associated with aortic penetrations during laparoscopic gastric band insertion at Kaleeya Hospital on 8 September 1999. The operation was undertaken for weight …

general surgeryanaesthesiaprocedural

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