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VIChospital2021-11-30

Finding into death of Eileen Violet Smith

88y · Female·Head injury in a fall due to atrial fibrillation on anti-coagulants

An 88-year-old woman with atrial fibrillation on anticoagulation died from a subdural haemorrhage sustained in a fall at a rehabilitation hospital. She was assisted to the toilet by a single nursing student despite a doc…

rehabilitation medicineneurosurgeryproceduralcommunication
QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

Teresa Bradford, aged 40, was killed by her husband David Bradford in a premeditated domestic homicide at their Pimpama home on 31 January 2017, followed by his suicide. She died from head injuries inflicted with an axe.…

general practicepsychiatrycommunicationsystemwarfarin
NSWcommunity2021-05-21

Inquest into the death of Pono Wairua Aperahama

17y · Male·Cardiac arrhythmia during restraint, with previous traumatic brain injury as a s…

Pono Aperahama, a 17-year-old with severe traumatic brain injury and moderate intellectual disability, died from cardiac arrhythmia during restraint at a swimming pool. His escalating behaviour in 2017—triggered by schoo…

neurologypsychiatrysystemcommunication
VIChome2021-05-07

Finding into death of Arthur John Smith

91y · Male·Gunshot wound to the head

Arthur Smith, 91, fatally shot his wife of 68 years before taking his own life. He had recently undergone cardiac surgery and expressed concerns about losing independence and being forced into care. The couple faced fina…

cardiothoracic surgeryrehabilitation medicine
VICaged care2021-04-23

Finding into death of Josephine Helen Clarke

69y · Female·Complications of a subdural haemorrhage (palliated) sustained in a fall

Josephine Helen Clarke, age 69, died from complications of a subdural haemorrhage sustained in a fall at Kingston Centre rehabilitation facility on 11 September 2018. Mrs Clarke had been recovering from a subarachnoid ha…

geriatric medicineneurosurgerysystemcommunication
VICcommunity2021-03-31

Finding into death of Bruce Vernon Taylor

53y · Male·Complications of old brain injury in prior motor vehicle incident

Bruce Vernon Taylor, 53, died from complications of a remote brain injury sustained in childhood motor vehicle accident. He lived in shared disability accommodation and received support through NDIS. In the 12 months bef…

general practiceneurologysodium valproate
VIChospital2020-11-25

Finding into death of Eoghan Jerome Arnold

42y · Male·Hypoxic ischaemic brain injury secondary to cardiac arrest caused by massive pul…

A 42-year-old man died from hypoxic ischaemic brain injury following cardiac arrest due to a massive pulmonary embolism. He sustained a tibial fracture in a motor vehicle accident and underwent external fixation. He deve…

orthopaedic surgeryanaesthesiasystemenoxaparin
TAShospital2020-05-05

Coroner's Finding: Tonks, Russell Rodney

Male·pneumonia, following injuries sustained in motor vehicle accident

Russell Rodney Tonks sustained severe head injury in a motor vehicle accident on 31 May 2010, resulting in global cerebral oedema, subdural haematoma, subarachnoid haemorrhage, and multiple fractures. He was admitted to …

neurosurgeryintensive care
SAaged care2020-02-28

Coroner's Finding: NISCO Sophia Alessia

16y · Female·upper airway occlusion due to aspiration of a foreign body (disposable latex glo…

Sophia Nisco, a 16-year-old with severe cerebral palsy and intellectual disability, died from airway obstruction after aspirating a disposable latex glove at a respite care facility. She had documented oral fixation beha…

rehabilitation medicinesupervisionsystem
WAhospital2019-07-30

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

7y · Male·cardiorespiratory failure in a child with cerebral palsy and epilepsy, with acut…

Child KT (Vinnie), age 7, died of cardiorespiratory failure from cerebral palsy and epilepsy after a prolonged hospital admission. He had complex medical needs including chronic respiratory disease, requiring PEG feeding…

paediatricsintensive caresystemmorphine
VIChospital2019-05-17

Finding into death of Mabel Grace Ellen Pritchard

90y · Female·Hospital acquired pneumonia in the setting of recent fractures of neck of humeru…

A 90-year-old woman with multiple comorbidities residing in aged care sustained a hip fracture from a fall in January 2018. Following surgical repair and initial hospital treatment, she was transferred to a rehabilitatio…

geriatric medicineorthopaedic surgerysystempiperacillin/tazobactam
VIChome2018-10-03

Finding into death of Yvonne Rose Vizard

72y · Female·Obstruction of the airways of the neck

A 72-year-old woman with moderate-severe expressive and receptive dysphasia following an acute left middle cerebral artery stroke died by hanging three months post-discharge from rehabilitation. Critical deficiencies wer…

neurologyrehabilitation medicinediagnosticsystem
SAaged care2018-02-08

Coroner's Finding: DILETTOSO Giuseppe

79y · Male·aspiration pneumonia

Giuseppe Dilettoso, aged 79, died of aspiration pneumonia at a nursing home where he was detained under guardianship orders. He had suffered two significant head injuries (2000 and 2013), with the latter requiring emerge…

general practiceintensive care
VIC2018-01-17

Finding into death of John Gale

64y · Male·Aspiration pneumonia in a man with dysphagia and acquired brain injury

John Gale, a 64-year-old man with acquired brain injury and severe intellectual disability living in state care, died from aspiration pneumonia following a fall and pneumonia diagnosis in May 2016. He was transferred bac…

general practicegastroenterologysystemdelay
NSW2017-11-09

Inquest into the death of David Veech

35y · Male·Fentanyl toxicity

David Veech, aged 35, died of accidental Fentanyl toxicity while residing at Tarlo Intensive Residential Support Service. He extracted Fentanyl from prescribed transdermal patches and injected it intravenously. Despite b…

general practicepsychiatrysystemcommunicationfentanyl
VIChome2017-06-21

Finding into death of Mrs DA

59y · Female·Multiple drug toxicity (propoxyphene, citalopram, oxazepam and others)

Mrs DA, aged 59, died from multiple drug toxicity (propoxyphene, citalopram, oxazepam and others) in March 2014. She had suffered a severe stroke in 2006 with resultant significant disability, chronic pain, and subsequen…

rehabilitation medicinegeneral practicepropoxyphene
NThome2017-05-05

Inquest into the death of Heather Fotiades

43y · Female·acute multiple drug toxicity on a background of chronic pain and morbid obesity

A 43-year-old woman died from acute multiple drug toxicity after 26 years of high-dose opioid therapy for chronic pain following a motor vehicle accident. Despite recognition by multiple clinicians that opioid doses exce…

general practicepain medicinediagnosticmedicationoxycodone
ACThome2017-03-23

AN INQUEST INTO THE DEATH OF PAP

55y · Male·Septicaemia due to hydronephrosis and infection

A 55-year-old man with complex medical and social problems died of septicaemia from renal infection. He had a history of cardiac disease requiring anticoagulation, alcohol dependence, depression, and chronic hoarding beh…

cardiologypsychiatrysystemcommunicationwarfarin
TAShospital2017-03-20

Coroner's Finding: Bird, Heather Mary

66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…

A 66-year-old woman died from retroperitoneal haemorrhage following anticoagulation for stroke caused by intra-arterial central venous catheter placement. The catheter was mistakenly inserted into the right carotid arter…

anaesthesiarehabilitation medicinediagnosticproceduralenoxaparin
QLDcommunity2016-12-21

Capps, Ruth

75y · Female·multiple injuries due to or as a consequence of motor vehicle collision

Ruth Capps, 75, died in a motor vehicle collision after drifting into oncoming traffic. She had multiple medical conditions including diabetes, sleep apnoea, chronic back pain, osteoarthritis, and recurrent falls. Despit…

general practiceoccupational therapydiagnosticcommunicationnitrazepam

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