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WA2002-05-03

Inquest into the Death of Gerhardus Theron

39y · Male·Ligature Compression of the Neck (Hanging)

Gerhardus Theron, 39, died by suicide in a remand centre on 25 June 2000 by ligature compression of the neck. He had murdered his wife on 28 April 2000 while their four children were present, and was remanded in custody.…

psychiatrycorrectional healthsystemanti-depressants
SAhospital2002-03-28

Coroner's Finding: PETROCCIA Assunta

26y · Female·cardiorespiratory arrest due to massive gastric dilatation with gastric rupture

Assunta Petroccia, a 26-year-old woman, died from cardiorespiratory arrest due to massive gastric dilatation with rupture following a bulimic episode. She presented to hospital with severe abdominal pain and was incorrec…

surgeryemergency medicinediagnosticcommunicationmorphine
SAcommunity2002-03-07

Coroner's Finding: GIBBONS Leith

17y · Male·incineration

A 17-year-old male died from incineration following a motor vehicle accident on 23 November 2000. The vehicle failed to negotiate a curve, left the road and struck a tree. The driver had bilateral lower limb fractures an…

forensic medicineemergency medicine
SA2002-02-27

Coroner's Finding: HARRADINE Robert and WILSON Anthony

Male·Robert Harradine: multiple injuries including brain stem transection, cerebral l…

Two teenagers died following a motor vehicle collision on 9 August 2000 in Adelaide. Robert Harradine (16) sustained fatal multiple injuries; Anthony Wilson (15) died from pulmonary contusion with associated injuries inc…

forensic medicineemergency medicinecannabis
VICcommunity2002-02-08

BEVERIDGE Graham

52y · Male·multiple injuries including right ventricular rupture

A 52-year-old volunteer race marshal was fatally struck by a detached Formula One race car wheel that passed through a gap in the debris fence at the 2001 Australian Grand Prix at Albert Park. The wheel was travelling at…

emergency medicineintensive caresystemdelay
SAhospital2002-02-05

Coroner's Finding: TAYLOR Margaret Joyce

56y · Female·subarachnoid haemorrhage complicating berry aneurysm of the right middle cerebra…

Margaret Joyce Taylor, aged 56, died from subarachnoid haemorrhage due to rupture of a berry aneurysm on the right middle cerebral artery. She presented to three medical practitioners over 6 days with progressive occipit…

general practiceemergency medicinediagnosticcommunicationparacetamol/codeine
SAhome2002-01-03

Coroner's Finding: THOMSON Wayne Mark

47y · Male·neck compression due to hanging

Wayne Mark Thomson, aged 47, died by hanging on 14 February 2000. He made multiple attempts to seek help for suicidal ideation in the preceding three days, including visiting his GP, calling a crisis assessment service (…

general practicepsychiatrydiagnosticcommunicationfluoxetine
WAcommunity2001-12-19

Inquest into the Death of Martin Raymond Coffey

24y · Male·Aspiration of vomit associated with combined drug effect

Martin Raymond Coffey, 24, died from aspiration of vomit associated with combined drug effect while on home detention after serving a prison sentence for traffic offences. He had a history of depression (following the de…

psychiatrygeneral practicesystemcommunicationamitriptyline
SAhospital2001-12-14

Coroner's Finding: OVERLAND Harold Kelvin

74y · Male·myocardial infarction

A 74-year-old male aged care resident died of myocardial infarction while detained under the Mental Health Act at Royal Adelaide Hospital. He had presented with hypokalaemia and sigmoid volvulus, refusing initial treatme…

emergency medicinecardiologyproceduralcommunication
NTcommunity2001-11-02

Inquest into the death of Nathan Wade Brooks

20y · Male·Electrocution resulting in cardiac arrhythmia and cardiac arrest

Nathan Wade Brooks, a 20-year-old roofer, died from electrocution on 20 March 2000 at Royal Darwin Hospital. While working on a construction site, he and a colleague were moving a mobile scaffold that had been raised to …

occupational and environmental healthoccupational therapysystemprocedural
NTcommunity2001-10-19

Inquest into the death of Clive Henry Impu

25y · Male·coronary thrombosis resulting from coronary atherosclerosis

A 25-year-old Aboriginal man with undiagnosed coronary artery disease collapsed and died one hour after a consultation at an Aboriginal health clinic. The coroner found the medical examination by Dr M. was inadequate and…

general practiceemergency medicinediagnosticcommunicationanti-inflammatory medications
SAhospital2001-10-19

Coroner's Finding: McCARTHY Nancy Clare

67y · Female·bronchopneumonia complicating disseminated pulmonary large cell carcinoma with r…

Nancy McCarthy, 67, presented with progressive back and chest pain initially attributed to vertebral compression fracture. She deteriorated acutely with confusion, agitation, and respiratory distress, necessitating Menta…

general practiceemergency medicinediagnostic
NT2001-10-16

Inquest into the death of Christopher Limerick

20y · Male·Unable to be determined. Death likely resulted from exposure following a fall wh…

Christopher Limerick, a 20-year-old Aboriginal man with alcohol dependency, was found dead at the bottom of Noble's Nob open-cut mine near Tennant Creek. Despite extensive investigation, the cause of death could not be d…

forensic medicineemergency medicinecommunicationsystem
NT2001-10-12

Inquest into the death of George Miller

40y · Male·multiple injuries sustained in a motor vehicle accident in which the deceased wa…

George Miller, a 40-year-old Aboriginal man with chronic alcohol dependence, was detained in protective custody at Katherine Police Station on 4 December 2000 after being found seriously intoxicated. After 7 hours detent…

emergency medicineforensic medicinealcohol
SAcommunity2001-10-05

Coroner's Finding: BEDNAREK Shantel Lisa

7y · Female·Multiple abdominal injuries including traumatic rupture of the liver and stomach…

A 7-year-old girl died from massive abdominal injuries sustained when a car, driven by an insulin-dependent diabetic man, collided with a group of pedestrians. The driver had undiagnosed and unaware hypoglycemia at the t…

endocrinologyemergency medicinediagnosticcommunicationinsulin
SAhospital2001-09-07

Coroner's Finding: SANDS Celia Laurel

82y · Female·peritonitis due to a perforated viscus (proximal jejunum) resulting from motor v…

An 82-year-old woman suffered a motor vehicle accident causing blunt abdominal trauma. Despite initial clinical assessment appearing adequate, a perforated jejunum with developing peritonitis was not diagnosed until earl…

general surgeryemergency medicinediagnosticdelay
SAhospital2001-09-04

Coroner's Finding: CHESTER George Spencer

18y · Male·multiple injuries

George Spencer Chester, 18, died from multiple injuries sustained when a stolen Toyota 4WD he was driving rolled on Decres Bay Road after failing to negotiate a bend while being pursued by police. He was ejected from the…

emergency medicinetrauma surgery
SAhospital2001-08-24

Coroner's Finding: GADALETA Saverio

28y · Male·Peritonitis and septic shock complicating perforation of the terminal small bowe…

A 28-year-old man with cerebral palsy, microcephaly, and epilepsy presented to the ED with abdominal pain, fever, and signs of deterioration. Triaged as Priority 3 despite these concerning features, he was not seen by a …

emergency medicinegeneral surgerycommunicationdelayparacetamol
NT2001-08-17

Inquest into the death of Blake Harvey

0y · Male·Burns from fire

A six-month-old child died from burns after a fire started at a roadhouse accommodation when his older sibling (5 years old) ignited a portable gas cooker with a cigarette lighter. The cooker was accessible in the room d…

emergency medicineretrieval medicineproceduralsystem
ACT2001-08

Inquest Into The Manner And Cause Of Death Of Brett Ponting

33y · Male·Cerebral hypoxia caused by drowning

A 33-year-old man with severe intellectual disability and cerebral palsy drowned in a bath at a supported accommodation house. Carers left him unattended in the bath despite an Individual Plan stating 'full assistance re…

geriatric medicineemergency medicinecommunicationsupervision

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