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QLD2009-08-21

Oram, Ronald Thomas

49y · Male·Coronary artery occlusion due to, or as a consequence of, coronary artery athero…

Ronald Thomas Oram, a 49-year-old Aboriginal man, died in custody from natural causes—severe coronary artery atheroma with coronary artery occlusion. He presented to the prison nurse on 5 January 2008 with chest pain, wh…

emergency medicinecardiologydiagnosticsystemparacetamol
SAcommunity2009-08-17

Coroner's Finding: TURNER Brian Raymond

59y · Male·ischaemic heart disease due to coronary atherosclerosis

Brian Raymond Turner, 59, died from ischaemic heart disease due to coronary atherosclerosis following an out-of-hospital cardiac arrest in a medical clinic car park. He experienced symptoms of chest discomfort and breath…

cardiologyemergency medicinecommunicationdelay
QLDhospital2009-08-13

Duggan, David John

60y · Male·Hypertensive heart disease with chronic fatty liver as other significant conditi…

David Duggan, a 60-year-old man with hypertensive heart disease and cardiomegaly, was admitted to Caloundra Hospital on 10 January 2007 for management of severe acute back pain caused by a suspected L3/4 disc herniation …

emergency medicinegeneral medicinesystemcommunicationoxycodone
SAhospital2009-08-12

Coroner's Finding: HOPE Maria Kate

55y · Female·hypoxic brain injury complicated by aspiration pneumonia

A 55-year-old woman with chronic schizophrenia died from hypoxic brain injury after suffocating herself with a plastic bin liner while hospitalised in a rural hospital. She was admitted following a disturbance where she …

general practicepsychiatrycommunicationdiagnosticolanzapine
SAhospital2009-07-30

Coroner's Finding: BRUNT Sidney

65y · Male·acute right subdural haematoma

Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…

general practiceemergency medicinemedicationcommunicationwarfarin
QLDhospital2009-07-10

Coleman, Randall John

39y · Male·Strychnine toxicity

Randall Coleman, 39, died from strychnine toxicity after deliberately ingesting poison while in custody at Kingaroy watchhouse on 18 January 2007. He had secreted the vial on his person at arrest on 16 January, despite p…

emergency medicinepsychiatrycommunicationdelaystrychnine
NThospital2009-06-30

Inquest into the death of Kenneth William Hill

37y · Male·complete blockage of the right anterior descending coronary artery with blood cl…

Kenneth Hill, a 37-year-old Aboriginal man, presented to Royal Darwin Hospital Emergency Department with chest pain and dyspnoea during football training. He was triaged as Category 3 by the triage nurse, who found his p…

emergency medicinecardiologysystem
SAcommunity2009-06-30

Coroner's Finding: SALAGARAS Steven

56y · Male·effects of heat exhaustion

Steven Salagaras, a 56-year-old charity collector, died from heat exhaustion on 22 January 2006 after working in extreme heat (40.8°C) during a heatwave. He was observed appearing physically distressed while collecting d…

occupational and environmental healthforensic medicinesystemdelay
SAaged care2009-06-26

Coroner's Finding: DAVIES Harold Leslie

87y · Male·multi organ failure due to septic shock complicating urinary tract infection and…

An 87-year-old man with atrial fibrillation on warfarin developed septic shock and multi-organ failure following traumatic bladder catheterisation. Two catheterisation attempts occurred on 15 July 2005: an unsuccessful a…

general practiceurologyproceduralcommunicationwarfarin
QLDcommunity2009-06-19

Hatch, Clay

34y · Male·gunshot wound to the neck

Clay Hatch, aged 34, with longstanding schizophrenia and recent amphetamine use, became acutely psychotic and took a supermarket cashier hostage at knifepoint after attempting to locate a gun shop. During police response…

psychiatryemergency medicinecommunicationsystemamphetamine
NTcommunity2009-06-10

Inquest into the death of Robert Plasto-Lehner and David Gurralpa aka Moscow

Male·David Gurralpa: sudden heart attack (coronary atherosclerosis with long-standing…

Two deaths resulted from police restraint in prone positions. David Gurralpa, a 39-year-old Aboriginal man with pre-existing coronary artery disease, died of sudden cardiac arrest following police restraint during a dome…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
NTcommunity2009-06-04

Inquest into the death of Kunmanara Forbes

15y · Female·Hanging (self-inflicted)

A 15-year-old Aboriginal girl in a remote Central Australian community died by suicide following a year marked by petrol sniffing, sexual abuse concerns, and reported suicide attempts. She suffered multiple sexually tran…

paediatricspsychiatrycommunicationsystem
SAhome2009-06-04

Coroner's Finding: PROBY Zak Dean

27y · Male·combined effects of penetrating injuries (crossbow arrows) to heart and brain

Zak Dean Proby, 27-year-old Aboriginal male, died from penetrating injuries from crossbow arrows to the heart and brain during a police siege on 21 June 2006. He had exhibited paranoid and disturbed behaviour for 9 days …

emergency medicinegeneral practicecommunicationmarijuana
QLDhospital2009-06-01

Woo, June

82y · Female·Hyperkalaemia due to acute renal failure on a background of end stage pulmonary …

An 82-year-old woman with terminal pulmonary fibrosis and chronic respiratory failure presented with chest pain, hyperkalaemia and metabolic acidosis. She became combative and was given haloperidol and morphine for agita…

emergency medicinerespiratory medicineaspirin
SAhospital2009-05-22

Coroner's Finding: ROBERTS Jarrad Delroy

10y · Male·sepsis (fusobacterium necrophorum) complicating right otitis media

Jarrad Roberts, a 10-year-old with learning disabilities and likely ADHD, died from sepsis due to untreated right otitis media caused by Fusobacterium necrophorum. He had been acutely ill for 5-7 days before finally seei…

paediatricsgeneral practicedelaysystemamoxicillin
SAhospital2009-05-21

Coroner's Finding: FARKAS Karl Derek

45y · Male·intracerebral haemorrhage caused by rupture of arterial aneurysm

A 45-year-old man with an intracerebral haemorrhage from a ruptured aneurysm presented to an emergency department and general practice on multiple occasions in October 2005 with headache, vomiting, dizziness, and neck st…

emergency medicinegeneral practicediagnosticcommunicationaspirin
VIChospital2009-05-20

Finding into death of Kara Lennah Compton

1y · Female·acute on chronic respiratory failure

Kara Compton, aged 22 months with Down's syndrome and chronic respiratory disease requiring home oxygen, died from acute on chronic respiratory failure following a dog bite attack. Injuries caused blood loss which, combi…

emergency medicinepaediatricsproceduralcommunicationadrenaline
SA2009-05-19

Coroner's Finding: O'KEEFFE Daniel William Barry

34y · Male·hypoxic encephalopathy following hanging

Daniel O'Keeffe, a 34-year-old male with amphetamine abuse and depression, died from hypoxic encephalopathy following hanging in Adelaide Remand Centre on 7 February 2007. He had attempted self-harm twice in custody afte…

psychiatryintensive caresystemcommunicationcitalopram
QLDhospital2009-05-13

Tilse, Therese Josephine

91y · Female·Sub-dural haemorrhage due to head injury due to fall

A 91-year-old woman was admitted to hospital after accidental paracetamol overdose and was found to have had a recent right occipital lobe infarction. While receiving appropriate care, she fell from her hospital bed at t…

emergency medicineradiologyparacetamol
ACThospital2009-04-28

Inquest Into The Death Of Stacey And Courtney Meas

Female·Stacey Meas: severe closed head injury from motor vehicle collision. Courtney Me…

Two deaths resulted from a motor vehicle collision caused by a driver with poorly managed insulin-dependent diabetes. Stacey Meas, a pregnant woman, died from head injuries sustained when the driver's car struck hers at …

endocrinologyemergency medicinesysteminsulin

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