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SA2004-08-06

Coroner's Finding: FREDERICKS Jeffrey Ronald

41y · Male·haemorrhage due to incised wounds to left and right cubital fossae

Jeffrey Ronald Fredericks, aged 41, died in Adelaide Remand Centre custody from haemorrhage due to self-inflicted incised wounds to both cubital fossae. Critical clinical lessons: screening tools identified significant s…

general practiceemergency medicinediagnosticcommunicationdosulepin
NThome2004-08-05

Inquest into the death of Stephen Power

35y · Male·left lower lobe pneumonia

Stephen John Power died of left lower lobe pneumonia on 5 September 2003 after two failed emergency calls requesting ambulance assistance. On Thursday 4 September, dispatcher Coralie Holland failed to send an ambulance d…

emergency medicineparamedicinecommunicationsystemflucloxacillin
SAhospital2004-07-30

Coroner's Finding: NOVAKOVIC Nikola

64y · Male·hypoxic encephalopathy, secondary to cardiac arrest, secondary to myocardial inf…

A 64-year-old man with paranoid psychosis, poorly controlled diabetes, ischaemic heart disease, atrial fibrillation, congestive cardiac failure, and chronic obstructive airways disease died from hypoxic encephalopathy fo…

psychiatrygeneral practicehaloperidol
SAmental health2004-07-30

Coroner's Finding: CURNOW Robert Norman

81y · Male·myocardial infarction

An 81-year-old man with dementia died of myocardial infarction while detained under Mental Health Act orders at Glenside Hospital. He was admitted for aggression and cognitive deterioration. Over three weeks, his psychia…

psychiatrygeneral practiceolanzapine
SAhospital2004-07-20

Coroner's Finding: QUINN Latoya Shelley

12y · Female·raised intracranial pressure due to ventriculo-peritoneal shunt blockage

A 12-year-old girl with congenital hydrocephalus and a ventriculo-peritoneal shunt presented to the ED with severe unrelieved headache after head trauma. An inexperienced junior doctor (6 weeks in role, minimal neurosurg…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
SAcommunity2004-07-16

Coroner's Finding: DINSDALE Cheree Ann and KLINGNER Peter James

20y · Unknown·Traumatic brain damage complicating gunshot wound to the head

Two young adults aged 20 died from gunshot wounds to the head on 29-30 May 2001 in what appears to be a murder-suicide involving Peter Klingner and his girlfriend Cheree Dinsdale. Klingner had paranoid schizophrenia with…

psychiatryemergency medicinediagnosticcommunicationolanzapine
SAhospital2004-07-15

Coroner's Finding: JOVANOVIC Katica

46y · Female·pulmonary thromboembolism due to bilateral deep calf vein thrombosis

A 46-year-old woman with schizo-affective disorder died from pulmonary thromboembolism secondary to bilateral deep vein thrombosis five days after involuntary psychiatric admission. She was severely withdrawn, refusing f…

psychiatrygeneral medicinediagnosticcommunicationzuclopenthixol
NThospital2004-07-02

Inquest into the death of John Colbert

55y · Male·Head injury from a fall, contributed to by chronic alcoholism and cirrhosis, res…

John Henry Colbert, a 55-year-old man with chronic alcoholism, Wernicke's encephalitis and cirrhosis, was admitted to Royal Darwin Hospital's ICU following a seizure. He was transferred to Ward 4A on 14 October 2002 and …

neurosurgeryemergency medicinesystemdelaydiazepam
WAhome2004-06-04

Inquest into the Death of Paul John Long

37y · Male·Acute Aspiration Pneumonitis following on Quetiapine Ingestion

Paul John Long, a 37-year-old man with chronic schizoaffective disorder and alcohol dependence, died on 4 November 2002 from acute aspiration pneumonitis following quetiapine overdose. After presenting to Avro Clinic in …

psychiatrygeneral practicecommunicationsystemquetiapine
SAhospital2004-05-19

Coroner's Finding: WOZNIAKOWSKI Andrzej

83y · Male·inanition with lobar pneumonia

An 83-year-old man with organic brain syndrome and severe malnutrition was detained under the Mental Health Act after being found in severe self-neglect. He was admitted to hospital where he received comprehensive multid…

emergency medicinepsychiatry
NTcommunity2004-04-21

Inquest into the death of Isiah Roberts

17y · Male·stab wound to the right side of the chest penetrating the lower right lung

Isiah Roberts, 17, died from a stab wound to the chest sustained during an altercation at Bagot Community. Stephen Barnes, whom Roberts had beaten one week prior, was identified as the assailant. The injury penetrated th…

forensic medicineemergency medicinealcohol
SA2004-04-06

Coroner's Finding: HUMBERSTONE Rex Alexander John

52y · Male·salt water drowning

A 52-year-old experienced recreational diver died from salt water drowning whilst diving near Marion Bay, South Australia. Multiple medical and equipment factors contributed: severe obesity (132kg), emphysema with lung b…

diving medicineforensic medicinediagnostic
SAcommunity2004-04-06

Coroner's Finding: CAMPBELL Deborah Christine

42y · Female·saltwater drowning

Deborah Campbell, aged 42, died from saltwater drowning while scuba diving at Nora Creina, South Australia. She was obese, physically unfit, and had not undergone proper diving medical evaluation. Contributing factors in…

diving medicineforensic medicinediagnosticsystem
SAcommunity2004-04-06

Coroner's Finding: BARRINGTON Jennifer Lee

44y · Female·salt water drowning due to ascent barotrauma (cerebral arterial gas embolism)

Jennifer Lee Barrington, age 44, died from salt water drowning due to ascent barotrauma (cerebral arterial gas embolism/CAGE) during a recreational scuba dive. She had significant undisclosed medical conditions including…

diving medicinehyperbaric medicinediagnosticcommunication
NT2004-03-19

Inquest into the death of Mansur La ibu

20y · Male·Undetermined cause (seizure-like episode with rapid death, epilepsy ruled out on…

Mansur La Ibu, a 20-year-old Indonesian fisherman, died suddenly on 26 February 2003 while detained on the fishing vessel Yamdena moored at Darwin Harbour. He experienced a seizure-like episode while confined in a small …

paramedicineemergency medicinesystemcommunication
WAcommunity2004-03-11

Inquest into the Death of Warren Bradley Jack

29y · Male·Head Injury

Warren Bradley Jack, 29-year-old fisherman, died from severe head injury after falling from a fishing vessel during a refuelling operation. On 24 April 2000, after returning from a fishing trip, he consumed approximately…

emergency medicineintensive carealcohol
NThospital2004-02-16

Inquest into the death of Maxwell Murphy

28y · Male·Cerebral contusions and fractured skull following a blow to the back of the head

Maxwell Theo Murphy, aged 28, died from cerebral contusions and a fractured skull sustained during a physical altercation on 10 January 2002. He was punched in the head by Jason Rogers during a fight and fell backward, s…

forensic medicineemergency medicine
SAhospital2004-02-13

Coroner's Finding: WHITE Kevin Charles

57y · Male·aspiration pneumonia secondary to small bowel obstruction

A 57-year-old man with chronic schizophrenia, intellectual disability, and history of bowel obstruction presented with faecal vomiting and signs of shock. He was appropriately transferred to hospital where small bowel ob…

emergency medicinesurgeryquetiapine
SA2004-02-13

Coroner's Finding: DEWSON Brian Keith

33y · Male·hanging

Brian Dewson, a 33-year-old man with a 12-year history of drug and alcohol abuse, multiple psychiatric assessments (antisocial personality disorder, depression), and prior suicide risk designations died by hanging in Por…

psychiatrycorrectional healthsystemcitalopram
SAhospital2004-02-13

Coroner's Finding: CUCUK Radomir

38y · Male·multi organ failure secondary to intestinal ischaemia from toxic megacolon relat…

A 38-year-old man with chronic schizophrenia died from multi-organ failure secondary to intestinal ischaemia caused by toxic megacolon from severe constipation. He was a detained patient on Clozapine and Oxybutamin, both…

psychiatryemergency medicineclozapine

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