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WAhome2000-05-08

Inquest into the Death of Kaitlin Alyce Gubanyi

4y · Female·Immersion (drowning)

Kaitlin Alyce Gubanyi, a healthy 4-year-old girl who could swim, drowned in a backyard swimming pool on 30 March 1999. While being supervised by a neighbour, Mrs Vicki Parr, the child was discovered face down in the pool…

emergency medicineintensive carecommunicationsystem
SAhospital2000-04-28

Coroner's Finding: SODY Caleb

20y · Male·ruptured heart and aorta due to fall from a height

A 20-year-old male with newly diagnosed disorganised schizophrenia died by suicide from a fall from the 5th floor of a hospital maternity building while detained under the Mental Health Act. He had been admitted to the C…

psychiatryemergency medicinesystemdelayolanzapine
SAmental health2000-04-28

Coroner's Finding: SCOTT Laurie Joseph

53y · Male·asphyxia due to upper airway occlusion by a foreign body (blanket)

A 53-year-old man with complex psychiatric disorder (schizophrenia, depression, intellectual disability) died by asphyxiation after stuffing a blanket into his mouth while in a High Dependency Unit of a psychiatric hospi…

psychiatryemergency medicinethioridazine
SAcommunity2000-04-14

Coroner's Finding: McTYE Alice Louise

34y · Female·hypoxic brain damage complicating fresh water drowning

Alice Louise McTye, a 34-year-old woman with severe intellectual disability and epilepsy, died from hypoxic brain damage following fresh water drowning in a bath at a disability services residence. The coroner found she …

neurologyintensive carecommunicationsystemcarbamazepine
SAhospital2000-03-24

Coroner's Finding: JAMES Kevin

70y · Male·spontaneous left frontal intracerebral haemorrhage

A 70-year-old man incarcerated at Yatala Labour Prison died from spontaneous left frontal intracerebral haemorrhage at Modbury Hospital. He had pre-existing chronic obstructive pulmonary disease, severe interstitial lung…

emergency medicineintensive care
SAcommunity2000-03-13

Coroner's Finding: STRANGWAYS Kenneth Charles

34y · Male·aspiration pneumonia following seizure with concomitant global severe anoxic enc…

Kenneth Strangways, a 34-year-old Aboriginal man with post-traumatic epilepsy, organic brain damage from head injuries, alcoholism and psychiatric illness, died from aspiration pneumonia following a seizure. The death wa…

psychiatryneurosurgerycommunicationsystemanticonvulsant medications
WAhome2000-03-10

Inquest into the Death of Michael James Dwyer

30y · Male·acute combined heroin and alcohol toxicity; ingestion of alcohol and heroin

Michael James Dwyer, a 30-year-old man, died on 17 June 1999 at Royal Perth Hospital from acute combined heroin and alcohol toxicity. On 11 June, after returning from Melbourne, he consumed approximately one litre of gin…

emergency medicineintensive caredelayheroin
SAhome2000-03-08

Coroner's Finding: KAPTSIS Michael Vasilious

3y · Male·smothering

A 3-year-old boy died from smothering by his mother, who was suffering from severe bipolar affective disorder with psychotic features and severe depression. The coroner examined whether psychiatric care was inadequate. T…

psychiatryemergency medicinelithium carbonate
SAhospital2000-02-25

Coroner's Finding: STONEHOUSE Jarrod William (aka Scott)

23y · Male·aspiration of blood due to stab wound to trachea

23-year-old man with self-inflicted stab wound to neck presenting to emergency department while intoxicated and agitated. Ambulance noted 3cm laceration to midline trachea with minimal external bleeding. Registered nurse…

emergency medicinesurgerydiagnosticcommunicationalcohol
ACT1999-08-05

In The Matter Of An Inquest Into The Death Of Ian Glen Bransby At Canberra On 14.2.98

31y · Male·extensive global cerebral hypoxia following prolonged asphyxia following attempt…

Ian Glen Bransby, a 31-year-old remandee with a history of substance abuse and depression, died from asphyxia following attempted hanging at Calvary Hospital on 14 February 1998. He had been remanded at Belconnen Remand …

psychiatrygeneral practicecommunicationsystemchlorpromazine
VIChospital1999-03-29

JONES Eric

33y · Male·Postural asphyxia due to restraint (Posey Poncho vest)

A 33-year-old male admitted after drug overdose died from asphyxiation while restrained in a Posey Poncho vest. Successfully treated for overdose complications, he developed drug-induced delirium with agitation, promptin…

intensive careemergency medicineproceduralsystemmethadone
ACTcommunity1999-02-26

In The Matter Of The Death Of Warren Geoffrey Ianson

Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…

Warren I'Anson died from gunshot wounds to the mid-back on 17 November 1995 during a police response to a mental health crisis. He had schizophrenia, recently experienced grief from his wife and friend's deaths, and was …

psychiatryemergency medicinecommunicationsystemdiazepam
NTcommunity1998-09-02

Inquest into the death of Esky Muller

14y · Male·Loss of blood arising from incised wound to the left arm (cubital fossa)

A 14-year-old Aboriginal petrol sniffer brought to a remote outstation (Ilpurla) without pre-arrangement died from massive haemorrhage following a self-inflicted laceration to his arm. Clinical lessons: petrol sniffers i…

emergency medicineaddiction medicinediagnosticsystempetrol
ACThospital1998-07-16

Inquest Into The Death Of Nathan Thomas James Wrench

0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…

Nathan Wrench, 11 weeks old, presented to Queanbeyan Hospital on 14 October 1996 with persistent vomiting for 3 days. GP Dr R. diagnosed viral infection with possible reflux, admitted for observation, and managed conserv…

paediatric surgeryemergency medicinecommunicationdiagnostic
TAShospital1996-10-01

Coroner's Finding: Muller Shar Marie

25y · Female·injuries sustained by jumping from the Tasman Bridge

A 25-year-old woman with longstanding borderline personality disorder, chronic suicidal ideation, and substance abuse died by jumping from the Tasman Bridge on 4 January 1996. She presented to the Emergency Department on…

psychiatryemergency medicinecommunicationsystemflunitrazepam
VIChospital1996-08-16

LONG June

69y · Female·Asthma

June Sylvia Long, aged 69, suffered an asthma attack at home on 28 June 1994 and was transported to Alfred Hospital. She deteriorated overnight in the hospital's Respiratory Ward despite initial improvement in Emergency …

respiratory medicineemergency medicinediagnosticcommunicationsalbutamol
NT1994-12-20

Inquest into the death of T. Okano, A. Kabe, T. Linklater and K. Pritchard (Cannonball Run)

Kabe 40, Okano 35, Linklater 22, Pritchard 31y · Male·Kabe and Okano: blunt head injury (head-to-head collision of occupants within ve…

On 24 May 1994, Ferrari F40 driver Akihiro Kabe entered a checkpoint lay-by at excessive speed (>100 kph, possibly 150 kph) following the 87.3 km mark where he mistakenly believed the checkpoint was located. The Ferrari …

emergency medicineforensic medicinedriver errorsystem error
NSWcommunity1990-07-18

Newcastle earthquake 1989 findings and recommendations

Multiple traumatic injuries sustained in earthquake-induced building collapse; o…

The 28 December 1989 Newcastle Earthquake (magnitude 5.6) killed 13 people: 9 in the Newcastle Workers Club collapse and 3–4 from Beaumont Street building failures. The coroner found that while the 1972 Club extensions l…

emergency medicine
WA28 Mar 24

Inquest into the Death of Suzzanne Denise DAVIS

47y · Female·ligature compression of the neck (hanging)

A 47-year-old woman remanded in custody at Melaleuca Women's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior…

psychiatryemergency medicinecommunicationsystemmethadone
VICcommunity

Finding into death of David Andrew Romanin

21y · Male·Sepsis and Streptococcus pyogenes necrotising fasciitis of the left leg

A 21-year-old university student sustained an ankle injury during an evening out and attended hospital ED the following day with ankle pain. X-rays showed no fracture and he was diagnosed with a sprained ankle, discharge…

emergency medicinegeneral practice

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