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ACTcommunity1999

Inquest Into The Death Of Katie Bender

12y · Female·Head injury caused by high-velocity steel fragment missile, approximately 999 gr…

Katie Bender, aged 12, was struck fatally in the head by a 999-gram steel fragment while watching the controlled implosion of Royal Canberra Hospital on 13 July 1997. The fragment travelled 430 metres in 3.1 seconds at 1…

occupational and environmental healthdiagnosticprocedural
NTcommunity1998-09-02

Inquest into the death of Esky Muller

14y · Male·Loss of blood arising from incised wound to the left arm (cubital fossa)

A 14-year-old Aboriginal petrol sniffer brought to a remote outstation (Ilpurla) without pre-arrangement died from massive haemorrhage following a self-inflicted laceration to his arm. Clinical lessons: petrol sniffers i…

emergency medicineaddiction medicinediagnosticsystempetrol
ACThospital1998-07-16

Inquest Into The Death Of Nathan Thomas James Wrench

0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…

Nathan Wrench, 11 weeks old, presented to Queanbeyan Hospital on 14 October 1996 with persistent vomiting for 3 days. GP Dr R. diagnosed viral infection with possible reflux, admitted for observation, and managed conserv…

paediatric surgeryemergency medicinecommunicationdiagnostic
ACThome1998-03-06

Inquest Into The Circumstances Surrounding The Death Of Brian Joseph Duff

36y · Male·Toxic overdose of Clozapine (anti-psychotic drug), self-administered, with termi…

Brian Duff, a 36-year-old with severe chronic schizophrenia, died from Clozapine toxicity (pulmonary oedema and cardiac arrest) on 14-15 February 1997. He was subject to a Community Treatment Order and under case managem…

psychiatrycommunicationsystemclozapine
VIC1997-10-17

KEW Residential Services

Male·smoke inhalation and burns

On 8 April 1996, a fire at Kew Residential Services killed nine intellectually disabled residents (aged 31–61) from smoke inhalation and burns when a resident used a cigarette lighter to ignite bedding. The coronial inqu…

systemdelay
ACT1997

Inquest Into The Circumstances Surrounding The Death Of Shannon Robert Camden

21y · Male·Suffocation from hanging

Shannon Robert Camden, a 21-year-old with longstanding mental health difficulties and previous suicide attempts, died by hanging in cell A1 of the Belconnen Remand Centre on 15 April 1996 while on remand awaiting trial f…

psychiatrypsychologyproceduralsystem
VIC1996-09-02

GALLAGHER GREEN Kevin

39y · Male·neck injuries from being crushed between a hydraulic ram and hydraulically opera…

Kevin Gallagher-Green, 39, died from neck injuries when crushed between hydraulic machinery at BHP Western Port Steel Works while attempting to adjust a tilt table height. The coroner identified multiple system failures:…

proceduralsystem
VIChospital1996-08-16

LONG June

69y · Female·Asthma

June Sylvia Long, aged 69, suffered an asthma attack at home on 28 June 1994 and was transported to Alfred Hospital. She deteriorated overnight in the hospital's Respiratory Ward despite initial improvement in Emergency …

respiratory medicineemergency medicinediagnosticcommunicationsalbutamol
NTcommunity1995-12-13

Inquest into the death of Azaria Chantel Loren Chamberlain

0y · Female·unknown

This coronial finding concerns the death of Azaria Chamberlain, a 9-week-old infant who disappeared from a tent at Ayers Rock on 17 August 1980. After her parents were convicted of murder and accessory after the fact (la…

pathologyforensic medicine
VIC1995-11-13

BALZAN Shane

Unknown·head injuries

Shane Balzan, a front-seat passenger, died from head injuries sustained in a motor vehicle collision at Bell Street and Gilbert Road, Preston on 15 May 1994. The collision occurred when a stolen Ford Falcon, driven by 15…

NT1994-12-20

Inquest into the death of T. Okano, A. Kabe, T. Linklater and K. Pritchard (Cannonball Run)

Kabe 40, Okano 35, Linklater 22, Pritchard 31y · Male·Kabe and Okano: blunt head injury (head-to-head collision of occupants within ve…

On 24 May 1994, Ferrari F40 driver Akihiro Kabe entered a checkpoint lay-by at excessive speed (>100 kph, possibly 150 kph) following the 87.3 km mark where he mistakenly believed the checkpoint was located. The Ferrari …

emergency medicineforensic medicinedriver errorsystem error
NTcommunity1991-06-03

Inquest into the death of Ganamu Garrawurra

48y · Male·shotgun wound to the head

A 48-year-old Yolngu man with chronic mental illness (schizophrenia) died from a shotgun wound to the head on Elcho Island, NT in April 1990. After spearing two people with a fishing spear, police Task Force was called t…

psychiatryforensic medicinesystemcommunicationmelleril
NSWcommunity1990-07-18

Newcastle earthquake 1989 findings and recommendations

Multiple traumatic injuries sustained in earthquake-induced building collapse; o…

The 28 December 1989 Newcastle Earthquake (magnitude 5.6) killed 13 people: 9 in the Newcastle Workers Club collapse and 3–4 from Beaumont Street building failures. The coroner found that while the 1972 Club extensions l…

emergency medicine
ACThospital1989-12-22

Inquest Into The Circumstances Surrounding The Death Of Alex Nicholas Mersiades

3y · Male·cerebral oedema which caused coning at the base of the brain, caused by post-ope…

A 3-year-old boy died from cerebral oedema caused by post-operative hyponatraemia following scoliosis correction surgery. The operation was successful, but severe hyponatraemia developed in the early hours of 24 April 19…

surgeryanaesthesiadiagnosticdelay
NTcommunity1981-12-17

Inquest into the death of John Ross Jabanardi

20y · Male·Retro-peritoneal and intra-peritoneal haemorrhage due to perforation of the left…

A 20-year-old Aboriginal man died from retroperitoneal and intra-peritoneal haemorrhage caused by perforation of the left internal iliac artery from a gunshot wound to the abdomen, inflicted by Constable Lawrence John Cl…

systemcommunication
NSW1980-12-19

Inquest into the deaths from the Appin Mine Disaster

Unknown·Explosion injuries and carbon monoxide poisoning from methane gas ignition in un…

On 24 July 1979, an explosion in Appin Colliery (NSW) killed 14 miners. The coroner determined the explosion resulted from ignition of methane gas in an unventilated B heading stub during a planned ventilation system cha…

communicationsystem
NSW1979-09-03

Inquiry into the fire and deaths at Luna Park

Unknown·Carbon monoxide poisoning and burns (or burns only in one case), accidentally su…

Seven children and teenagers died in the Luna Park Ghost Train fire on 9 June 1979 when the timber-framed building became engulfed in dense smoke and flames. The fire likely originated from a carelessly discarded cigaret…

systemdelay
WA28 Mar 24

Inquest into the Death of Suzzanne Denise DAVIS

47y · Female·ligature compression of the neck (hanging)

A 47-year-old woman remanded in custody at Melaleuca Women's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior…

psychiatryemergency medicinecommunicationsystemmethadone
WAprison

Inquest into the Death of Ian HEAD

74y · Male·cardiac arrhythmia in an elderly man with chronic obstructive pulmonary disease …

Ian Head, a 74-year-old man with chronic obstructive pulmonary disease, hypertension, and chronic kidney disease, died from cardiac arrhythmia following COVID-19 infection while imprisoned at Acacia Prison. He had receiv…

general practiceemergency medicinecommunicationsystemparacetamol
WA

Inquest into the Death of Stanley John INMAN

19y · Male·complications of ligature compression of the neck

Stanley John Inman, 19-year-old Aboriginal male, died by suicide at St John of God Midland Hospital on 13 July 2020, two days after ligature compression of the neck at Acacia Prison. He was on low-level ARMS (at-risk man…

psychiatrypsychologycommunicationsystemmirtazapine

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