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WAhome2022-12-08

Inquest into the Death of Child B (Name Subject to Suppression Order)

3y · Male·Hypoxic ischaemic encephalopathy complicating hypoglycaemia with shock and statu…

A 3-year-old boy with septo-optic dysplasia and panhypopituitarism died from hypoxic ischaemic encephalopathy secondary to adrenal crisis and hypoglycaemic shock. He was in state care and had an emergency management plan…

endocrinologypaediatricssystemdelayhydrocortisone
WAhospital2022-10-05

Inquest into the Death of David Arthur RICE

75y · Male·acute bronchopneumonia in a man with comorbidities

A 75-year-old sentenced prisoner died from acute bronchopneumonia with comorbidities. Mr Rice had extensive medical complexity including COPD, cardiac disease, peripheral vascular disease, and diabetes. He was appropriat…

general medicinecardiologysystemapixaban
WA2022-08-05

Inquest into the Death of Michael James HARDIE

41y · Male·haemothorax due to ruptured thoracic aortic aneurysm in a man with Marfan syndro…

A 41-year-old man with Marfan syndrome and a thoracic aortic aneurysm managed conservatively with blood pressure medications died from aneurysm rupture while imprisoned. Methylamphetamine in his system significantly elev…

cardiologyvascular surgerycommunicationsystemmethamphetamine
WAhospital2022-08-01

Inquest into the Death of Ronald Joseph BUCKLAND

70y · Male·bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidi…

Ronald Joseph Buckland, aged 70, died in custody at Fiona Stanley Hospital from bronchopneumonia with intra-abdominal carcinoma and multiple comorbidities. A life-sentenced prisoner, he had extensive medical conditions i…

cardiologygastroenterologysystemcommunication
WA2022-07-20

Inquest into the Death of Seth Gregory Victor YEEDA

19y · Male·Rheumatic heart disease (severe aortic valve regurgitation)

Seth Yeeda, 19-year-old Aboriginal male with rheumatic heart disease from childhood, died in custody from severe aortic valve regurgitation. He had required aortic valve replacement surgery since 2014. In December 2017, …

cardiologycardiothoracic surgerysystemcommunication
WA2022-07-06

Inquest into the Death of Paul Stephen KEATING

60y · Male·atherosclerotic heart disease (cardiac arrhythmia secondary to severe long-stand…

Paul Stephen Keating, a 60-year-old man with severe atherosclerotic heart disease, died from cardiac arrhythmia while incarcerated in Casuarina Prison, Western Australia. He had significant coronary artery disease diagno…

cardiologycorrectional healthamiodarone
WA2022-06-21

Inquest into the Death of Ashley Adrian LANE

56y · Male·acute exacerbation of chronic obstructive pulmonary disease (bronchial asthma) i…

Ashley Adrian Lane, a 56-year-old Aboriginal man from the Ngaanyatjarra Lands, died in custody at Kalgoorlie Regional Hospital from acute exacerbation of chronic obstructive pulmonary disease (asthma). He was a remand pr…

respiratory medicineemergency medicinediagnosticcommunicationsalbutamol
WAhospital2022-06-08

Inquest into the Death of Salvatore Giovanni OTRANTO

68y · Male·Complications following myocardial infarction and its treatment in a man with mu…

Salvatore Otranto, a 68-year-old prisoner with multiple severe comorbidities including ischaemic heart disease, diabetes, COPD, and chronic kidney disease, died from complications of myocardial infarction and its treatme…

cardiologyintensive careproceduralenoxaparin
WA2022-05-20

Inquest into the Death of Kevin Ernest McCRACKEN

58y · Male·Hypertensive and valvular heart disease

Kevin McCracken, 58, died of hypertensive and valvular heart disease following sudden cardiac collapse in a prison pre-release unit. He had complex pre-existing cardiac disease including previous valve replacement and ao…

cardiologycorrectional healthsystemmedicationwarfarin
WAhospital2022-01-05

Inquest into the Death of Terrence Alexander Penman WELLS

61y · Male·metastatic oesophageal neuroendocrine carcinoma

Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attribut…

oncologypalliative caremedicationsystempantoprazole
WAmental health2021-10-22

Inquest into the Death of Russell David BROCKLISS

38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…

Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute car…

psychiatryemergency medicinedelaysystemrisperidone depot
WAprison2021-09-06

Inquest into the Death of Marshall Ruben EDGILL

38y · Male·combined effects of acute-on-chronic respiratory disease and cardiomegaly

Marshall Ruben Edgill, a 38-year-old Indigenous man, died in custody from acute-on-chronic respiratory disease and cardiomegaly. He had longstanding obstructive sleep apnoea (OSA), obesity, asthma, and hypertension. Crit…

respiratory medicinecardiologydiagnosticdelay
WAhome2021-08-26

Inquest into the Death of Baby E (Name Subject to Suppression Order)

0y · Male·Complications of VATER syndrome and sacrococcygeal teratoma

Baby E was a 7-month-old neonate with VATER syndrome and sacrococcygeal teratoma who died from complications of these conditions. He was born prematurely at 30 weeks, requiring intubation and ventilation, and remained in…

neonatologynephrology
WAhospital2021-08-06

Inquest into the Death of Hassan Mohamed YOUSSEF

60y · Male·Complications of gastrointestinal haemorrhage due to cirrhosis of the liver seco…

Hassan Mohamed Youssef, a 60-year-old sentenced prisoner, died from gastrointestinal haemorrhage complications secondary to cirrhosis from hepatitis B. He presented with multiple serious pre-existing conditions including…

gastroenterologyhepatology
WAhospital2021-08-06

Inquest into the Death of Alex Carl MILLS

76y · Male·Sepsis, with osteomyelitis and infective endocarditis

Alex Mills, a 76-year-old sentenced prisoner with complex medical history including atrial fibrillation, valvular heart disease, and rheumatoid arthritis, died from sepsis caused by osteomyelitis and infective endocardit…

infectious diseasescardiologydiagnosticdelayprednisolone
WAhospital2021-07-30

Inquest into the Death of Chad RILEY

39y · Male·Cardiac arrhythmia following violent exertion necessitating physical restraint i…

39-year-old Chad Riley died from cardiac arrhythmia following violent exertion during physical restraint. He presented to hospital intoxicated with methylamphetamine, exhibiting drug-induced psychosis with agitation and …

emergency medicinepsychiatrysystemmethamphetamine
WAhome2021-06-22

Inquest into the Death of Child AM (Name Subject to Suppression Order)

3y · Female·bronchopneumonia in an infant with obstructive sleep apnoea

A 3-year-old Aboriginal girl died from bronchopneumonia complicated by severe obstructive sleep apnoea. She had rapid-onset childhood obesity (36 kg at death; normal weight 14-16 kg) with multiple cardiopulmonary complic…

paediatricsrespiratory medicinecommunicationsystem
WAcommunity2021-04-13

Inquest into the Suspected Death of Sebastian POULSON

38y · Male·Unascertained; most likely exposure after walking in bushland

Sebastian Poulson, age 38, disappeared from Wangkatjunka Community in remote Western Australia on 19 October 2014. He had serious cardiac conditions including rheumatic heart disease, decompensated congestive heart failu…

cardiologyemergency medicine
WAhospital2021-01-04

Inquest into the Death of Baby JDU

0y · Male·Scimitar syndrome

An 11-week-old term infant (Baby JDU) died from Scimitar syndrome, a rare congenital heart and lung disorder with bilateral complications including pulmonary hypoplasia, venous obstruction, and severe pulmonary hypertens…

cardiologyneonatologysildenafil
WA2020-12-22

Inquest into the Death of Jordan Robert ANDERSON

23y · Male·hypoxic brain injury and bronchopneumonia complicating ligature compression of t…

Jordan Robert Anderson, 23, died by suicide in Hakea Prison through ligature compression of the neck. Critical delays occurred when he was discovered unresponsive: 3 minutes 40 seconds elapsed before his cell door was un…

emergency medicinecardiologyproceduralcommunication

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