Coronial
WAhospital2013-11-12

Inquest into the Death of Ford, Valma May Ruth

77y · Female·Complications following a recent fracture and surgical repair of the right hip i…

A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Ke…

orthopaedic surgeryemergency medicinediagnosticsystemwarfarin
QLDhome2020-06-02

Lee, Mason Jet

1y · Male·Abdominal injuries (perforation of small bowel and mesentery with peritonitis pr…

Mason Lee, aged 22 months, died on 11 June 2016 from abdominal injuries inflicted by his mother's partner, William O'Sullivan, combined with severe neglect. Mason was admitted to hospital in February 2016 with severe per…

paediatricsinfectious diseasesdiagnosticsystemmethamphetamine
NSW2024-12-03

Inquest into the death of Simon Cartwright

41y · Male·Septicaemia secondary to chronic peptic ulcer disease

Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer history diagnosed in November 2020 and sho…

psychiatrygastroenterologydiagnosticsystempantoprazole
SAhospital2010-07-09

Coroner's Finding: STEMMER Jessica Lee and MAHAR Thomas William

Jessica: disseminated intravascular coagulation following haemorrhage (subgaleal…

Two neonates died from complications of subgaleal haemorrhage following ventouse extraction. Jessica Stemmer (7 hours old) died from disseminated intravascular coagulation after subgaleal haemorrhage. Thomas Mahar (8 day…

obstetricsneonatologydelaycommunication
QLDhospital2016-11-04

Neitsch, Horst - non-inquest findings

77y · Male·Stroke; cardiogenic shock; severe aortic stenosis with three vessel coronary art…

Mr Neitsch, a 77-year-old with severe aortic stenosis, peripheral vascular disease, and reduced left ventricular function, underwent elective coronary angiography at Princess Alexandra Hospital on 21 May 2015. The proced…

cardiologyvascular surgeryproceduralcommunicationfurosemide
VIChome2016-03-24

Finding into death of Caroline Emily Lovell

36y · Female·Global ischaemic injury following cardiorespiratory arrest in the immediate post…

Caroline Lovell, 36, died from postpartum haemorrhage following home birth of her second child. She had significant risk factors: prior PPH with first child and uterine fibroid, but these were not properly investigated b…

midwiferyobstetricsdiagnosticcommunicationsyntocin
WApolice custody2017-03-31

Inquest into the Death of Maureen MANDIJARRA

44y · Female·unascertained (consistent with Streptococcus dysgalactiae and Staphylococcus aur…

Maureen Mandijarra, a 44-year-old Aboriginal woman with poorly controlled diabetes and recurrent skin infections, was arrested at Male Oval on 29 November 2012 for street drinking under a zero-tolerance police approach. …

emergency medicineinfectious diseasesdiagnosticcommunicationalcohol
WAcommunity2019-02-07

Inquest into the 13 Deaths of Children and Young Persons in the Kimberley Region

Ligature compression of the neck (hanging) in 12 cases; one open finding

This complex coronial inquest examined 13 Aboriginal children and young persons who died by suicide in the Kimberley Region between 2012–2016. The coroner found 12 deaths were suicides and one open finding. Common contri…

psychiatrypaediatricsdiagnosticcommunicationalcohol
NTcommunity2020-12-15

Inquest into the death of Fionica James, Katurah Mamarika, Layla Leering

Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…

Three Aboriginal teenage girls aged 15-17 years died by hanging in remote NT communities, all with documented histories of sexual abuse, domestic violence, STIs, injuries, and severe trauma. All were known to government …

paediatricspsychiatrydiagnosticcommunicationalcohol
NSWhospital2021-10-22

Inquest into the death of Ivan Goolagong

68y · Male·Metastatic Pancreatic Adenocarcinoma

Ivan Leo Goolagong, a 68-year-old Wiradjuri man, died of metastatic pancreatic adenocarcinoma while in Long Bay Prison Hospital Medical Subacute Unit in July 2017, five months after undergoing a Whipple procedure. The co…

oncologypalliative caresystemcommunicationamylase
1910

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