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QLD2020-05-22

McGuire, Paul Thomas

Male·Asphyxia, caused by the inhalation of severely oxygen-depleted air

Paul McGuire, an experienced mine electrician, died from asphyxiation after opening a partially sealed hatch door to a GOAF (worked-out coal area) containing severely oxygen-depleted air. The critical failure was the min…

systemcommunication
QLDrural hospital2020-05-08

FD - Non-inquest findings

68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…

A 68-year-old woman with oculopharyngeal muscular dystrophy died from sepsis due to peritonitis following dislodgement of a PEG tube inserted on 27 February 2018. She presented to a rural hospital 5.5 hours post-discharg…

gastroenterologyemergency medicinediagnosticcommunicationaugmentin duo
QLDhome2020-05-06

T and P - Non-inquest findings

Female·Drowning

Two young sisters, aged 4 and 3 years, drowned in a residential swimming pool while unsupervised. Both parents were present in the home but inattentive—the mother was asleep in the bedroom while the father was using his …

paediatricsemergency medicinesupervisionsystem
QLDcommunity2020-04-17

Russo, Matthew Anthony

37y · Male·Cardiac failure due to sepsis due to bilateral bronchopneumonia

Matthew Russo, a 37-year-old man, died from sepsis and cardiac failure secondary to bilateral bronchopneumonia within 18 hours of consultation with Dr M.. The coroner found the medical treatment inadequate and inappropri…

general practicerespiratory medicinediagnosticcommunicationamoxicillin
QLDhome2020-03-30

Hinder, Nyobi Jade; Hinder, River James & Hinder, Charlie

7y · Female·Explosion caused intentionally by Charlie Hinder; children died instantly from b…

Three deaths resulted from an intentional explosion caused by Charlie Hinder in a caravan containing himself and his two children (ages 4 and 7) during marital separation. Charlie had perpetrated coercive controlling dom…

communicationsystem
QLDhome2020-03-11

Roulant, Daniel Christopher

22y · Male·Meningococcal meningitis and sepsis

Daniel Roulant, 22, died from meningococcal meningitis and sepsis within 24 hours of symptom onset. He presented to his GP on 23 November 2017 with a viral head cold, low-grade fever (37.4°C), and normal ENT/chest examin…

general practiceinfectious diseases
QLD2020-03-10

March 2014 plane crash at Caboolture Airfield

Unknown·Each deceased died as a result of injuries sustained in an aircraft crash: Andre…

Five people died in a Cessna U206G aircraft crash during tandem parachuting operations at Caboolture Airfield on 22 March 2014. The aircraft aerodynamically stalled shortly after take-off, the precise cause could not be …

aviation medicinesystemprocedural
QLDcommunity2020-03-06

Jones, Paige Erin

30y · Female·Chest and abdominal injuries sustained in a motorcycle accident

Paige Jones, aged 30, died from severe chest and abdominal injuries sustained in a motorcycle crash. The critical issue was whether she was the rider or passenger. While Mr White (her partner) consistently claimed he was…

forensic medicineemergency medicinemethamphetamine
QLDPodcast2020-02-24

Goodchild, Kate; Dorsett, Luke; Low, Cindy & Araghi, Roozbeh

Multiple severe internal and external injuries as a result of multiple compressi…

Four adults died when Raft 5 collided with a stationary Raft 6 on the Thunder River Rapids Ride at Dreamworld on 25 October 2016. The primary cause was south pump failure causing rapid water level drop, which stranded Ra…

systemdelay
QLDcommunity2020-02-20

Parker, Lee Edward

47y · Male·Smoke inhalation and effects of fire

Lee Edward Parker, 47, died in a bus fire at a caravan park in Queensland in August 2016. Heavy alcohol consumption by multiple residents that evening created a chaotic scene. Evidence suggests Parker entered a female re…

emergency medicineforensic medicinesystemdelay
QLDPodcast2020-01-24

Willersdorf, Maria

87y · Female·Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular hear…

An 87-year-old woman died following a CT-guided epidural injection at a private radiology clinic. Although she had undergone the procedure for spinal pain, the radiologist performed an epidural injection at the T12 level…

radiologypain medicinediagnosticproceduralbupivacaine
QLDhospital2019-12-06

Taylor, Darren Rodney

52y · Male·Metastatic neuroendocrine carcinoma

Darren Rodney Taylor, a 52-year-old Indigenous man, died in custody from metastatic neuroendocrine carcinoma diagnosed in March 2017. He presented with abdominal pain initially attributed to constipation, then found to h…

oncologypalliative caremorphine
QLDhospital2019-12-06

Lahrs, Brendon John

27y · Male·Metastatic sarcoma

Brendon Lahrs, a 27-year-old prisoner, died from metastatic Ewing's sarcoma (CIC-DUX4 translocation type) in March 2017. He presented with a persistent cough in April 2016 and was initially managed with Ventolin for susp…

oncologyrespiratory medicinesalbutamol
QLDhospital2019-12-06

Burgess, Terence Neil

50y · Male·Ischaemic and valvular heart disease (severe aortic stenosis) with other signifi…

A 50-year-old man with severe ischaemic and valvular heart disease (aortic stenosis) died suddenly in hospital following multiple myocardial infarctions. He had consistently refused invasive interventions including valve…

cardiologypalliative careheparin
QLDhospital2019-12-05

Skilton, Robert Douglas

73y · Male·Lung cancer (squamous cell carcinoma)

Robert Skilton, aged 73, died of advanced squamous cell carcinoma of the lung while in prison custody. He had a 59-year smoking history and consistently declined medical care throughout 43 years of incarceration, with up…

respiratory medicineoncologysystemmorphine
QLDhospital2019-12-05

Pascoe, Rodney Dick

53y · Male·Pneumonia due to hepatic encephalopathy due to cirrhosis; chronic pancreatitis w…

A 53-year-old Aboriginal man with advanced alcoholic liver cirrhosis died in hospital while in custody. He had end-stage liver disease, hepatic encephalopathy, and multiple comorbidities (diabetes, ischaemic heart diseas…

gastroenterologyhepatologymorphine
QLD2019-12-05

Harrison, Steven Leslie

61y · Male·Coronary atherosclerosis

Steven Harrison, aged 61, died of sudden coronary atherosclerosis while incarcerated at Wolston Correctional Centre. He had multiple cardiovascular risk factors including Type 2 diabetes, heavy smoking history, and intra…

cardiologygeneral practicediagnosticsystemmetformin
QLDhospital2019-12-05

Burrows, Frank Leslie

58y · Male·Haemophagocytic lymphohistiocytosis, due to or as a consequence of T-cell lympho…

Frank Burrows, a 58-year-old male prisoner, died from Haemophagocytic Lymphohistiocytosis (HLH) secondary to T-cell lymphoma. He presented with non-specific symptoms (fever, sweats, diarrhoea) and was initially discharge…

general medicinehaematologydexamethasone
QLD2019-11-21

Gavenor, Ashley Glenfield

48y · Male·Coronary atherosclerosis and minor trauma

Ashley Glenfield Gavenor, a 48-year-old Indigenous man with coronary artery disease, hypertension, diabetes, and bipolar affective disorder, died in Townsville Correctional Centre following a brief altercation with anoth…

cardiologypsychiatryaspirin
QLDhome2019-11-06

Follent, Mitchell James - Non-inquest findings

22y · Male·Multiple injuries from fall from height

Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired b…

psychiatryneurologydiagnosticcommunicationolanzapine
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