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QLD2005-07-08

Pugh, Samuel

46y · Male·Cardiac failure due to blood loss from traumatic laceration to right thigh susta…

Samuel Pugh, a 46-year-old mining contractor, died from cardiac failure due to blood loss after being struck by a 219 kg falling rock underground at a Queensland mine. He suffered a severe laceration to his right thigh w…

occupational and environmental healthemergency medicinecommunicationsystem
WAhome2005-07

Inquest into the Death of taylor

29y · Male·Penetrating wound to neck with vascular injury to the carotid sheath

Louis Bernard Taylor, a 29-year-old Aboriginal male, died from a penetrating wound to the neck inflicted by himself on 23 August 2002. Recently released from prison after four years incarceration, Louis was attempting to…

psychiatrygeneral practicecannabis
WAhospital2005-06-30

Inquest into the Death of Daniel Allan Sullivan

48y · Male·Hypoxic brain injury following cardiac arrest in a patient with sigmoid colon vo…

Daniel Allan Sullivan, a 48-year-old man with chronic paranoid schizophrenia who had been an involuntary patient at Graylands Hospital for 23 years, presented to Sir Charles Gairdner Hospital on 13 June 2004 with abdomin…

emergency medicinegeneral surgeryclozapine
WAhospital2005-06-30

Inquest into the Death of Reginald Brian O'Neill

45y · Male·Intra Abdominal Haemorrhage Associated with Metastatic Carcinoma of the Oesophag…

Reginald Brian O'Neill, a 45-year-old sentenced prisoner at Karnet Prison Farm, died from intra-abdominal haemorrhage associated with metastatic oesophageal carcinoma on 6 December 2003. In late November 2003, he present…

general medicinegastroenterologyheparin
WAmental health2005-06-30

Inquest into the Death of Jessica Mary Dewhurst

20y · Female·Ligature compression of the neck

Jessica Mary Dewhurst, aged 20, died by ligature compression of the neck on 27 May 2003 in the secure ward of Swan Adult Mental Health Services. She had a history of depression, psychosis, substance abuse, and prior suic…

psychiatrygeneral medicinefluoxetine
NThospital2005-06-27

Inquest into the death of Bradley Abala

12y · Male·astrocytoma (brainstem, posterior fossa tumour with hydrocephalus and brainstem …

Bradley Abala, a 12-year-old Aboriginal boy, died from an aggressive brainstem astrocytoma on 23 April 2004. He presented with a three-month history of headaches, coordination difficulties, and lethargy. CT imaging on 20…

neurosurgerypaediatricscommunication
SAhospital2005-06-03

Coroner's Finding: SORENSEN Ruth Bengta Maria

69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…

A 69-year-old woman presented to the Emergency Department with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood t…

emergency medicinesurgerydiagnosticcommunicationprochlorperazine
SAhospital2005-06-02

Coroner's Finding: GREEN Marie

64y · Female·Respiratory arrest secondary to morphine overdosage on a background of mild to m…

A 64-year-old woman died from respiratory arrest secondary to morphine overdose after ingesting 17 tablets of slow-release morphine (Kapanol) and diazepam. Initial emergency assessment by an intern was appropriate, but c…

emergency medicinegeneral medicinecommunicationdiagnosticmorphine
WAhospital2005-06

Inquest into the Death of Ilija Kocovski

72y · Male·Subarachnoid haemorrhage in a man with coronary arteriosclerosis

Ilija Kocovski, a 72-year-old man with a history of ischaemic heart disease, presented to Royal Perth Hospital Emergency Department on 22 October 2000 with chest pain, nausea, vomiting, and headache after arriving in Per…

emergency medicinecardiologyheparin
SAprison2005-05-31

Coroner's Finding: McLEOD Ian

45y · Male·bronchopneumonia and suppurative bronchitis complicating hypoxic brain damage

Ian McLeod, a 45-year-old lawyer with alcohol dependence and depression, died from hypoxic brain damage and bronchopneumonia following a hanging while in custody at Yatala Labour Prison. Multiple system failures contribu…

psychiatrycorrectional healthdiagnosticcommunicationdiazepam
SAhospital2005-05-24

Coroner's Finding: WALLACE-MOHLMANN Candice Mackenzie

30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…

Candice Mackenzie Wallace-Mohlmann, a 30-year-old woman with chronic schizophrenia and substance abuse history, died from hypoxic brain injury caused by self-injection of vecuronium and atropine obtained from a hospital …

psychiatryemergency medicinediagnosticmedicationvecuronium
NTcommunity2005-05-10

Inquest into the death of Jacky Barakal

54y · Male·Coronary Atherosclerosis contributed to by Pulmonary Emphysema

A 54-year-old Aboriginal male died at home in Maningrida from acute coronary atherosclerosis complicated by emphysema. He experienced chest pain and dyspnea during the night and his family made three telephone calls to t…

emergency medicinecardiologycommunicationdelay
QLDhospital2005-05-04

Robinson, Jacinta Kate

7y · Female·cardiac tamponade due to total parenteral nutrition fluid leakage into the peric…

A 7-year-old girl with spina bifida died from cardiac tamponade caused by total parenteral nutrition (TPN) fluid leaking into the pericardial sac via a central venous line inserted during bowel obstruction surgery. Clini…

paediatric surgeryanaesthesiadiagnosticcommunicationtotal parenteral nutrition
WAhome2005-05-01

Inquest into the Death of Christopher Nigel Spinks

35y · Male·Acute Staphylococcus aureus Meningitis

Christopher Nigel Spinks, a 35-year-old tree surgeon, died of acute Staphylococcus aureus meningitis on 3 December 2002. He initially presented on 27 November 2002 with neck pain following a windsurfing accident. Dr R. n…

general practiceemergency medicinediagnosticdelaynurofen plus
WAcommunity2005-05

Inquest into the Death of Adam David McKay

31y · Male·Pulmonary thromboembolism arising from deep vein thrombosis

Adam David McKay, a 31-year-old geologist, died from pulmonary thromboembolism arising from deep vein thrombosis on 23 January 2003. He had recently completed extensive long-haul flights to West Africa and returned on 13…

general practiceemergency medicinediagnosticcommunication
WAhospital2005-05

Inquest into the Death of Olivia ("Peta") Dawson

26y · Female·Asphyxiation due to Ligature Compression of Neck

Peta Dawson, a 26-year-old woman with a history of depression, self-harm, and suicidal ideation following miscarriage and maternal rejection, was admitted to Merredin Hospital on 10 August 2003 after presenting with wris…

emergency medicinepsychiatrysystemdelaykalma
SAhospital2005-04-12

Coroner's Finding: KARTINYERI Richard John

60y · Male·respiratory failure and sepsis complicating acute subdural haematoma

Richard Kartinyeri died 44 days after exiting a moving vehicle during a police pursuit. He sustained a severe right-sided acute subdural haematoma, cerebral contusions and skull fractures requiring emergency neurosurgery…

neurosurgeryintensive caremorphine
SA2005-04-11

Coroner's Finding: POTTER Claire Elizabeth

26y · Female·multiple injuries sustained as a result of being struck by a motor vehicle on th…

A 26-year-old woman with schizo-affective disorder, detained under the Mental Health Act, absconded from a psychiatric hospital and was fatally struck by a vehicle on a freeway. Clinical concerns include: (1) inadequate …

psychiatryemergency medicinecommunicationsystemolanzapine
SAhospital2005-04-07

Coroner's Finding: HARRIS Margret Lillian

48y · Female·Chronic Obstructive Airway Disease

Margret Lillian Harris, aged 48, died of chronic obstructive airway disease while detained under the Mental Health Act at Royal Adelaide Hospital. She had longstanding COAD, right heart failure, chronic hypoxia and cyano…

psychiatryrespiratory medicinediuretics
NThospital2005-04-06

Inquest into the death of Peter Wiryal

48y · Male·Cerebrovascular Accident (stroke) caused by subdural haemorrhage, which resulted…

Peter Wiryal, 48, was struck by a white van driven by an intoxicated Daniel Johnson along George Crescent, Fannie Bay at approximately 12:30am on 4 April 2003. He was discharged from Royal Darwin Hospital on 4 April afte…

emergency medicineneurosurgerydiagnosticcommunicationalcohol

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