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NThospital2007-12-10

Inquest into the death of Ricky Ryder

28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…

A 28-year-old Aboriginal male died from hypovolemic shock following operative exploration of multiple stab wounds to the thigh. The death was preventable. Critical failures included: delayed surgery from Friday to Saturd…

general surgeryorthopaedic surgerydiagnosticsystem
QLDhospital2007-12-07

Burgen, Deborah Denise

49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…

Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with identical …

emergency medicinesurgerydiagnosticdelayparacetamol/codeine
QLD2007-11-29

Mills, Samuel John

31y · Male·Self-inflicted hanging

Samuel John Mills, a 31-year-old man with chronic schizophrenia, died by suicide in Lotus Glen Correctional Centre's medical ward in 2004. Staff provided adequate supervision on the day of death; Mills denied self-harm i…

psychiatryemergency medicinesystemcommunicationmelleril
QLD2007-11-28

Tanner, Marjorie Joyce

Female·Coronary atherosclerosis with ischaemic small bowel and Alzheimer's disease

Marjorie Joyce Tanner, an elderly woman with Alzheimer's disease, presented to Maryborough Hospital with a three-day history of abdominal pain, distension, and vomiting. Initially diagnosed with simple constipation and t…

general medicinesurgerydiagnosticsystemmetoclopramide
QLDhospital2007-11-23

Scholz, Karl David

31y · Male·Upper airway obstruction due to pharyngeal abscess caused by dental abscess, whi…

Karl Scholz, 31-year-old male, died from upper airway obstruction due to pharyngeal abscess originating from untreated dental infection. He presented with severe facial cellulitis and abscess following dental procedures …

intensive careanaesthesiadiagnosticcommunicationamoxicillin
QLD2007-11-23

Walker, Nola Jean

66y · Female·Blood loss due to tearing of the spleen and fractured ribs occasioned by a motor…

Nola Walker, a 66-year-old retired nurse, died from splenic rupture and haemorrhage caused by blunt force trauma from a motor vehicle accident. She was involved in a minor crash, assessed by paramedics who found normal v…

emergency medicineparamedicinediagnosticcommunicationalcohol
QLDhospital2007-11-23

Bodell, Margaret Florence Anne

65y · Female·gastrointestinal haemorrhage from duodenal ulcer

Margaret Bodell, 65-year-old with severe COAD and emphysema, was admitted with respiratory failure and developed a duodenal ulcer bleeding during hospitalisation. Critical clinical lessons include: (1) careful oxygen man…

respiratory medicinegeneral medicinecommunicationsystemprednisone
QLDhome2007-11-22

Hanley, Timothy Michael

19y · Male·poisoning by diphenhydramine and dextromethorphan from 'Herbal Ecstasy'

Timothy Michael Hanley, aged 19, died from poisoning by diphenhydramine and dextromethorphan after ingesting 'Herbal Ecstasy' purchased online. This case highlights the dangers of unregulated internet-sourced compounds, …

toxicologyemergency medicinediphenhydramine
NThome2007-11-13

Inquest into the death of Richard Kiel

37y · Male·acute heart failure caused by multiple drug toxicity (methadone and alprazolam)

Richard Mark Kiel, a 37-year-old with chronic opioid addiction, died from acute heart failure caused by lethally high levels of methadone and alprazolam, likely consumed on 9 September 2005. His GP, Dr G., prescribed the…

general practiceaddiction medicinediagnosticmedicationmethadone
NTcommunity2007-11-12

Inquest into the death of Angel Blanco-Puerto, Phillip Lindsay, Barry Gaykamangu and Hannu Kononen

Male·Angel Blanco-Puerto: acute heart failure as result of long-standing damage from …

Four men died from acute heart failure after ambulance officers declined or inadequately pursued hospital transport. In Angel Blanco-Puerto, no potentially life-threatening condition was identified at the time. However, …

emergency medicinecardiologydiagnosticcommunication
SAhome2007-11-09

Coroner's Finding: RANDALL Treenor Heather

50y · Female·mixed tablet overdosage (quetiapine and venlafaxine with codeine)

Treenor Heather Randall, a 50-year-old registered nurse, died from mixed tablet overdose (quetiapine and venlafaxine) following a progressive mental health decline. After work-related stress in late 2002, she developed d…

general practicepsychiatrycommunicationdelayquetiapine
QLDhospital2007-10-30

Noffke, Veronica Margaret

73y · Female·coronary atherosclerosis

A 73-year-old woman admitted with severe respiratory distress was appropriately managed in ICU with intubation and extubated after 8 days. She was transferred to coronary care as stable but deteriorated with cardiorespir…

emergency medicineintensive careanticoagulants
QLDhospital2007-10-01

Fogarty, Kevin Edward

37y · Male·Community acquired pneumonia as a result of melioidosis infection

Kevin Fogarty, a 37-year-old power lineman, died from melioidosis-related community-acquired pneumonia at Winton Hospital after a 4-day admission. He likely contracted melioidosis through occupational exposure to mud dur…

general practiceemergency medicinediagnosticcommunicationdiazepam
QLDhospital2007-09-27

Effer, Anthony John

27y · Male·exsanguination due to ruptured right kidney, renal vessels, and liver from motor…

Anthony John Effer, aged 27, died from exsanguination following a high-speed motorcycle crash on 26 July 2004. He was a pillion passenger on a motorcycle that left the road at speed and struck a concrete culvert, causing…

emergency medicinetrauma surgeryalcohol
SAhospital2007-09-18

Coroner's Finding: MARKANTONAKIS Stefanos

63y · Male·uncontrolled haemorrhage from ruptured aortic aneurysm

A 63-year-old man presented with sudden back pain on 6 March 2004. Ambulance officers attended twice; on the first visit they did not transport him to hospital despite his request, misattributing his symptoms to musculos…

emergency medicineparamedicinediagnosticcommunicationparacetamol/codeine
WAhome2007-09-14

Inquest into the Death of Jones Coronial

9y · Male·Head injury (epidural haematoma with cerebral coning following craniotomy)

Dwayne Michael Jones, aged 9, had Trisomy 10, a rare congenital chromosomal disorder causing severe developmental delay and neurological abnormalities. On 11 April 2000, he fell from a computer desk and struck his head. …

general practiceemergency medicinediagnosticdelayparacetamol
QLDhospital2007-09-03

Henderson, Robert Joseph

31y · Male·mixed drug toxicity

Robert Henderson, 31, died from mixed drug toxicity while subject to a community involuntary treatment order for schizophrenia. He was admitted to hospital on 9 July 2005 after his case manager appropriately identified e…

psychiatryemergency medicinediagnosticdelaymorphine
QLDcommunity2007-08-24

Case, Matthew Colin

3y · Male·drowning

Matthew Colin Case, aged 3 years 11 months, drowned in the main pool at Goodna Aquatic Centre on 24 September 2005 while unsupervised. His mother left him and four other children at the pool complex stating she would ret…

emergency medicinepublic healthsystemcommunication
QLDhospital2007-08-17

Mental Health patient

71y · Male·hypoxic brain injury due to hanging

A 71-year-old farmer with a 10-year history of major depressive disorder with melancholic features died by hanging on 22 July 2005, three days after admission to a private psychiatric hospital (Belmont) following a medic…

psychiatryemergency medicinecommunicationdiagnostictemazepam
SAhospital2007-08-02

Coroner's Finding: GILLAM Peter Roy

44y · Male·Sepsis and pulmonary thromboemboli complicating a ruptured cerebral artery aneur…

Peter Gillam, age 44, died from sepsis and pulmonary thromboemboli complicating a ruptured cerebral aneurysm with subarachnoid haemorrhage (SAH). On 16 December 2004, his GP Dr H. referred him urgently for CT head to exc…

emergency medicinegeneral practicediagnosticcommunicationsalbutamol

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