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VIChome2022-05-03

Finding into death of Carol Austin

65y · Female·Plastic bag asphyxia

Carol Austin, 65, died by plastic bag asphyxia at her home in Wangaratta in August 2018. She had a 20-year history of depression and had recently experienced suicidal ideation, a suicide attempt, and burns injury requiri…

psychiatrygeneral practicesystemcitalopram
VIC2022-03-21

Finding into death of Nilofer Nezami

38y · Female·Unascertained

Nilofer Nezami, a 38-year-old Victorian resident, died on 7 January 2019 following cosmetic surgery in Iran. She underwent multiple procedures including eye, breast, arm and abdominal surgery. Post-operatively, she devel…

plastic and reconstructive surgeryanaesthesiasystemproceduralmorphine
VIChospital2022

Finding into death of Ms S

63y · Female·Sepsis complicating cellulitis following skin cancer excision and skin graft pro…

A 63-year-old woman died from sepsis complicating cellulitis following elective skin cancer excision and skin graft performed in a general practitioner's clinic. The lesion was a squamous cell carcinoma (invasive Bowen's…

general practiceplastic and reconstructive surgeryantibiotics
QLDhospital2021-11-01

Masoumali, Omid

24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns

Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement.…

plastic and reconstructive surgeryintensive carecommunicationsystem
VIChospital2020-07-07

Finding into death of Marek Koziol

61y · Male·Injuries sustained in motor vehicle collision (pedestrian)

A 61-year-old legally blind man was struck by a motor vehicle while crossing a busy highway with his guide dog. He sustained severe head injuries including subarachnoid and subdural haemorrhage, and diffuse axonal injury…

trauma surgeryintensive care
QLDcommunity2020-06-26

Nyholt, Nicole Sonia and Clark, Margaret Louisa

Female·Burns due to gas explosion due to motor vehicle collision with building

A 60-year-old man with a long-standing history of seizures experienced an epileptic seizure while driving and lost control of his vehicle. It collided with an LPG gas cylinder outside a café, triggering an explosion that…

emergency medicineneurologycommunicationsystem
NSWhospital2020-01-31

Inquest into the death of OS

5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …

A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…

plastic and reconstructive surgeryanaesthesiamedicationproceduralmorphine
NSWhome2019-10-04

Inquest into the death of C D

60y · Male·burn wounds and the consequences thereof

CD, a 60-year-old man with long-standing psychiatric history (schizophrenia/schizoaffective disorder) and alcohol use disorder, set his house alight on 19 September 2017 after becoming acutely unwell with paranoid ideati…

general practicepsychiatrydiagnosticcommunicationdiazepam
NSWaged care2019-09-27

Inquest into the death of Epenesa PAHIVA

87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…

Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (h…

dermatologygeneral practicediagnosticcommunicationbleach
WAhospital2019-08-02

Inquest into the Death of Timothy James CHANDLER

52y · Male·multiple organ failure and pulmonary thromboemboli complicating generalised seps…

A 52-year-old man with longstanding refusal of medical care presented with severe cellulitis, sepsis, and previously undiagnosed heart failure secondary to sleep apnoea. He lacked capacity to consent to treatment due to …

emergency medicinegeneral medicine
VIChospital2019-08-01

Finding into death of Tyla Jade Hovenbitzer

18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…

An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…

paediatricsgeneral practicesystemdelaytemazepam
ACThome2019-06-04

Inquest into the death of Lauren Maree Johnstone

48y · Female·Combined toxic effect of prescription and non-prescription medications including…

Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…

general practicesurgerycommunicationsystemdoxylamine
NSWhospital2019-03-01

Inquest into the death of Stephen Kline

51y · Male·Pulmonary thromboemboli due to deep vein thrombosis on a background of a leg bur…

Stephen Kline, a 51-year-old Aboriginal man, died from pulmonary thromboembolism due to deep vein thrombosis following a leg burn wound sustained when NSW Police deployed a taser during a confrontation on 8 March 2016. H…

plastic and reconstructive surgerypsychiatrydiagnosticsystemheparin
VIChospital2018-08-31

Finding into death of David William Lobb

53y · Male·Complications of burns sustained in a blast

A 53-year-old qualified boiler maker died from complications of severe burns sustained in a gas explosion. While attempting to remove a refrigeration compressor from a hotel cellar with an unqualified colleague, they cut…

intensive caretrauma surgeryproceduralsystem
NSWhome2018-07-06

Inquest into the death of Miata Jibba

9y · Female·complications of thermal injury

A 9-year-old child died from severe thermal injuries sustained in a house fire. The property had non-functional smoke alarms that the property management company knew about but failed to remedy or report to the landlord.…

intensive careplastic and reconstructive surgerycommunicationsystem
VIChome2017-12-04

Finding into death of Leigh Thomas Aiple

31y · Male·Pulmonary thromboembolism

A 31-year-old man with obesity (BMI 40.2) and sleep apnoea underwent extensive cosmetic surgery in Malaysia (liposuction, abdominoplasty, chest lipectomy, and subsequent facial procedures) across two operations within fi…

plastic and reconstructive surgerygeneral surgerydiagnosticmedicationenoxaparin
WAcommunity2017-06-12

Inquest into the Death of Wendy BEARFOOT

45y · Female·multiple organ failure following thermal injuries (severe burns)

Wendy Bearfoot, a 45-year-old DEC (Department of Environment and Conservation) employee, died from multiple organ failure following severe thermal burns (80% of body) sustained in a bushfire burnover on 12 October 2012. …

emergency medicineplastic and reconstructive surgerycommunicationdiagnostic
NSW2016-11-14

Inquest into the death of AA

43y · Male·complications of thermal injuries

A 43-year-old man with a history of workplace injury, financial stress, and social isolation attended a workers compensation office in Newcastle carrying mineral turpentine and a cigarette lighter. After about 23 minutes…

psychiatryemergency medicine
NSW2016-07-15

Inquest into the death of Sheila Drysdale

75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …

A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…

plastic and reconstructive surgerygeriatric medicinemedicationproceduralaspirin
QLDaged care2016-06-15

Drane, John Edward

75y · Male·Burns

75-year-old John Drane, a resident of Masonic Care Queensland, died from extensive burns on 9 January 2014. The coroner concluded he intentionally set himself alight using a cigarette lighter shortly after receiving his …

oncologygeriatric medicinediagnosticcommunicationchemotherapy agents

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