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WAhospital2013-02-11

Inquest into the Death of Carroll

21y · Male·Acute hypoxic ischaemic encephalopathy and pneumonia in a man with recent trauma…

Peter Martin Carroll, age 21, died on 8 June 2007 in the ICU at Royal Perth Hospital from acute hypoxic ischaemic encephalopathy and pneumonia following oxycodone overdose. He had been discharged that day (5 June) after …

emergency medicineorthopaedic surgerycommunicationsystemoxycodone
WAhome2013

Inquest into the Death of Blinkhorn, Leah Christine

29y · Female·Multiple Drug Toxicity (Lamotrigine, Doxylamine, Venlafaxine, Valproic Acid, Cod…

A 29-year-old woman with personality disorders and depression called Perth Clinic at 11:11pm reporting she had overdosed on multiple medications (lamotrigine, doxylamine, venlafaxine, valproic acid, codeine, morphine). S…

psychiatryemergency medicinediagnosticcommunicationlamotrigine
WA2013

Inquest into the Death of Ms D

39y · Female·Septic shock and nosocomial pneumonia secondary to pentobarbital (Nembutal) over…

A 39-year-old woman with major depression and Cluster B personality traits died by suicide in Mexico following a pentobarbital overdose on 28 April 2008, resulting in septic shock and nosocomial pneumonia. She had been a…

psychiatryintensive caresystemdelaypentobarbital
WAhome2013

Inquest into the Death of Deniro, Alen

28y · Male·Gunshot wound to the head

Alen Deniro died by suicide on 5 May 2011 after learning of his de facto partner's death from terminal lung cancer. Psychiatrists appropriately assessed him as high suicide risk and initiated involuntary detention proced…

psychiatrygeneral medicinecommunication
WAhome2013

Inquest into the Death of Hurley-Goodacre, Adam Michael

17y · Male·Ligature Compression of the Neck (Hanging) - Suicide

Adam Hurley-Goodacre, a 17-year-old Ward of the State since 1996, died by suicide on 20 February 2007, one week before his 18th birthday. He had a history of suicide attempts in October 2006 while experiencing emotional …

paediatricspsychiatrysystemalcohol
WAmental health2013

Inquest into the Death of Ibbotson, Graeme Ross

57y · Male·Ischaemic Heart Disease

A 57-year-old man with extensive medical history including ischaemic heart disease, hypertension, hypercholesterolaemia and chronic airways disease died of acute myocardial infarction whilst being transferred by ambulanc…

psychiatrycardiologyprednisolone
WAhome2013

Inquest into the Death of Stevens, Malachi Isaac and Stevens, Lochlan James

10y · Male·Unascertainable

Two young children, Malachi (10 months) and Lochlan (2 years), died on 7-8 November 2008 in their mother's home en suite, with cause of death unascertainable. The mother claimed to have blacked out for approximately 10 h…

paediatricsforensic medicinesystemdelay
WAmental health2013

Inquest into the Death of Vos, Glenis June

60y · Female·Focal pneumonia in a woman with emphysema and ischaemic heart disease

A 60-year-old woman with long-standing schizophrenia/bipolar disorder, emphysema, and ischaemic heart disease died of focal pneumonia at Graylands Hospital. She had been an involuntary patient with multiple prior respira…

psychiatrygeneral medicinetemazepam
WAhospital2013

Inquest into the Death of Zappacosta, Palmerino

86y · Male·Sepsis associated with a pericolic abscess, complicated by terminal large intest…

An 86-year-old life-sentenced prisoner died from sepsis associated with a pericolic abscess complicated by terminal gastrointestinal haemorrhage. He had extensive comorbidities including bilateral amputations, cardiac fa…

emergency medicinegeneral medicinevenlafaxine
WAhospital2012-08-31

Inquest into the Death of Stone

62y · Female·Multiple injuries sustained from jumping from rocks at Torndirrup National Park …

Pamela Stone, a 62-year-old woman with a complex history of trauma, depression and relationship difficulties, presented to Albany Regional Hospital ED on 26 March 2009 after a violent altercation at home, having been sed…

emergency medicinegeneral practicesystemcommunicationmidazolam
WAhospital2012-06-27

Inquest into the Death of LEE

37y · Male·Respiratory arrest in association with medication drug effect and alcohol intoxi…

David James Lee, a 37-year-old Aboriginal man with schizophrenia, died on 15 July 2007 at Port Hedland Regional Hospital from respiratory arrest associated with medication effect and alcohol intoxication. He arrived at t…

emergency medicinepsychiatrymedicationcommunicationchlorpromazine
WAhospital2012-05-31

Inquest into the Death of GARRETT

52y · Male·HIV infection complicated by basal and squamous cell carcinoma of the head and n…

Bruce Jason Garrett, a 52-year-old prisoner detained under the Dangerous Sexual Offenders Act, died at Royal Perth Hospital on 2 October 2010 from HIV infection complicated by basal and squamous cell carcinoma of the hea…

emergency medicineintensive careheparin
WAhome2012-04

Inquest into the Death of BENFIELD

0y · Female·Unascertainable

Shar Rose Benfield, a 7-month-old Aboriginal infant born prematurely to parents with significant psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child …

paediatricspsychiatrysystemdelay
WAhospital2012-03-30

Inquest into the Death of Ellery

25y · Male·Ligature compression of the neck (hanging)

David Peter Ellery, a 25-year-old man with long-standing amphetamine addiction and deteriorating mental health, died by hanging on 31 July 2007. He presented to Bentley Hospital on 31 July with active suicidal ideation, …

emergency medicinepsychiatrycommunicationsystemamphetamine
WA2012-01-12

Inquest into the Death of Brennan

38y · Male·Exsanguination due to penetration of arm veins

Declan Brennan, a 38-year-old sentenced prisoner at Acacia Prison due for release on 30 April 2008, died by suicide on 27 April 2008 from exsanguination due to penetrating wounds to his arm veins. Brennan had a long-stan…

psychiatrycorrectional healthsystemdelaylithium
WAhospital2012

Inquest into the Death of Keogh

38y · Female·Pulmonary Thromboembolism

Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…

general surgeryintensive carecommunicationdelaywarfarin
WAhospital2011-11-22

Inquest into the Death of Ashdown

27y · Male·cardiac arrhythmia during restraint; mechanism involved hypoxia and asphyxiation…

Warwick Andrew Ashdown, a 27-year-old male with severe treatment-resistant paranoid schizophrenia, died at Graylands Hospital on 12 October 2007 from cardiac arrhythmia during physical restraint. After assaulting another…

psychiatryintensive careproceduralsystemhaloperidol
WAcommunity2011-10-21

Inquest into the Death of Balgo

Male·Ashton Michael Sunfly: ligature compression of the neck (hanging); Mitchell Nana…

This coronial inquiry examined five deaths in Balgo Aboriginal Community over a 24-month period: four suicides by hanging and one death from volatile substance abuse. The suicide rate in Balgo was more than 100 times the…

general practicepsychiatrysystemdelaypetrol
WAmental health2011-04-21

Inquest into the Death of Barnes

50y · Female·acute heart failure in association with acute on chronic obstructive airways dis…

Donna Lillian Barnes, a 50-year-old woman with chronic schizophrenia and multiple physical comorbidities including morbid obesity, asthma, and poor mobility, died of acute heart failure associated with acute-on-chronic o…

psychiatrygeneral medicinecommunicationsystemantibiotics
WAhospital2010-02-04

Inquest into the Death of Hudson

20y · Male·Ligature compression of the neck (hanging)

Allan Kevin Hudson, a 20-year-old male with a history of depression, suicidality, substance abuse and previous sexual trauma, died by hanging on 13 August 2006 at Sir Charles Gairdner Hospital's psychiatric ward D20. He …

psychiatryemergency medicinediagnosticcommunicationcarbamazepine
111121315

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