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VIC2014-05-21

Finding into death of Michael Patrick Ormsby

9y · Male·Motor vehicle accident related multi trauma

Michael Ormsby, a 9-year-old boy with severe autism spectrum disorder and intellectual disability requiring constant supervision, died from multi-trauma injuries sustained in a motor vehicle accident. While under respite…

paediatricsrisperidone
VIChospital2014-05-20

Finding into death of Angela Therese Thompson

51y · Female·Aspiration pneumonia in a woman with Down syndrome and Alzheimer's dementia

Angela Thompson, a 51-year-old woman with Down syndrome and early-onset Alzheimer's dementia, died from aspiration pneumonia following a shoulder fracture. She was in DHS supported residential care when she suffered freq…

general practicepsychiatrysystemcommunicationescitalopram
NSWhospital2014-05-09

Inquest into the death of Tama GALIERE

0y · Unknown·focal ventricular myocarditis and myonecrosis resulting from migration of a Peri…

A 10-month-old boy died from myocarditis and myonecrosis caused by migration of a PICC line into his right ventricle. The line was inserted appropriately under general anaesthetic for IV antibiotics treating periorbital …

paediatricsanaesthesiaproceduralcommunication
QLDcommunity2014-03-25

Baby T - Non-inquest findings

0y · Unknown·Hypoxic ischaemic encephalopathy resulting from cardiorespiratory arrest due to …

A three-week-old infant died from asphyxia while positioned in an over-the-shoulder infant sling at a shopping centre. The baby had recent upper respiratory tract infection with RSV, which reduced respiratory reserve. Th…

paediatricsemergency medicinesystem
VIChospital2014-03-21

Finding into death of Michelle Johnson

31y · Female·Ruptured splenic artery aneurysm with extensive retroperitoneal and intraperiton…

Michelle Johnson, a 31-year-old pregnant woman at 32 weeks gestation, presented to the Royal Women's Hospital with sudden-onset severe left-sided abdominal pain and hypotension on 21 March 2010. She was assessed by regis…

obstetricsemergency medicinecommunicationsystempethidine
VIChome2014-03-06

Finding into death of Melanie Jane Maher

36y · Female·Effects of fire (schizophrenic psychotic episode); for children: effects of fire…

This case involved the deaths of Kylie Fowler (36) and her three children—Samantha (18), Melanie (13), and Matthew (11)—in a house fire on 9 January 2011. Kylie, with an 18-year history of schizophrenia requiring five in…

psychiatrygeneral practicecommunicationsystemrisperidone
VIChome2014-03-06

Finding into death of Kylie Jane Fowler

36y · Female·Effects of Fire

A 36-year-old woman with a 18-year history of schizophrenia killed herself and her three children (ages 11, 13, and 18) in a house fire with stab wounds on 9 January 2011. Ms Fowler had five involuntary psychiatric admis…

psychiatrygeneral practicecommunicationsystemrisperidone
VIChome2014-03-06

Finding into death of Matthew Patrick James Maher

36y · Female·Effects of fire and stab wounds (for Matthew Maher); effects of fire (for Kylie …

Kylie Fowler, a 36-year-old woman with a 18-year history of schizophrenia requiring five involuntary psychiatric admissions, killed herself and her three children (Melanie, 13; Matthew, 11; Samantha, 18) on 9 January 201…

psychiatrypaediatricscommunicationsystemrisperidone
VIChome2014-03-06

Finding into death of Samantha Jane Fowler

36y · Female·Effects of fire and stab wounds (Kylie Fowler); effects of fire (Melanie Maher);…

Kylie Fowler, a 36-year-old woman with severe schizophrenia and a 18-year history of involuntary psychiatric admissions, killed her three children (Samantha 18, Melanie 13, Matthew 11) and herself by stabbing and fire on…

psychiatrypaediatricscommunicationsystemrisperidone
VIChospital2014-02-24

Finding into death of Baby Jacob Hill

0y · Male·complications of intrauterine hypoxia

Baby Jacob Hill died from intrauterine hypoxia following an obstructed labour managed at Sunshine Hospital. A 39-week primiparous labour was complicated by deep transverse arrest. After initial assessment suggesting caes…

obstetricspaediatricscommunicationdelaypethidine
VIChospital2014-01-22

Finding into death of Hannah McNeil

0y · Female·Pulmonary hypoplasia in the setting of ascending maternal genital tract infectio…

Hannah McNeil, a term neonate, died from pulmonary hypoplasia secondary to ascending maternal genital tract infection. She was born via emergency caesarean section after induction of labour for brow presentation. Despite…

obstetricsneonatologydelaycommunicationoxytocin
WAcommunity- 28 March 2014

Inquest into the Death of Hayley DIAMOND

14y · Female·Acute cerebral hypoxia arising out of suffocation due to inhalation of toxic vap…

Haley Diamond, 14, died from acute cerebral hypoxia following inhalation of volatile substances (deodorant spray) in Kununurra, WA. She suffered acute brain damage and bronchopneumonia. Clinical lessons: volatile substan…

emergency medicineintensive carecommunicationsystemlynx deodorant spray
NThome2013-12-18

Inquest into the death of Miss M

15y · Female·cardiac and respiratory arrest following pulmonary aspiration

Miss M, a 15-year-old Aboriginal girl with severe cerebral palsy and multiple medical complications, died from cardiac and respiratory arrest due to pulmonary aspiration. She had an Advance Care Directive (ACD) in place …

paediatricsemergency medicinesystem
VIChospital2013-12-09

Finding into death of JM

17y · Female·Combined Drug Toxicity (heroin, alprazolam and diazepam)

A 17-year-old female with complex mental health and substance use disorders died from combined drug toxicity (heroin, alprazolam, and diazepam) following release from youth detention. Despite extensive involvement from d…

psychiatryaddiction medicinecommunicationsystemheroin
SAaged care2013-11-29

Coroner's Finding: BETTS Lawrence

9y · Male·sigmoid volvulus

Lawrence Betts, a 9-year-old Aboriginal boy with Goldenhar syndrome and developmental disability including pica (ingesting foreign substances), died from sigmoid volvulus complicated by ingestion of soil, sand, and stone…

paediatricsgastroenterologysupervisionsystem
WAhospital2013-11-28

Inquest into the Death of Scafidas, Allegra Amelie

0y · Female·Pneumococcal meningitis

Allegra, aged 6 months, died of pneumococcal meningitis after a Healthdirect telephone triage call on 28 April 2010 that resulted in inappropriate home-care advice. She presented with fever (38.9°C), shallow rapid breath…

paediatricsinfectious diseasesdiagnosticsystemparacetamol
QLDhospital2013-09-12

Bligh, William John - Non-inquest findings

9y · Male·Disseminated melioidosis

William Bligh, a 9-year-old boy from Palm Island, died from disseminated melioidosis on 24 February 2013. He presented with fever and cough from 2 February, initially assessed as viral illness. Over 11 days, he was revie…

paediatricsinfectious diseasessystemdelayibuprofen
QLDhospital2013-09-05

Sparreboom, Sophie Claire - Non-inquest findings

0y · Female·Cerebral hypoxia due to placental abruption

Sophie Sparreboom died from cerebral hypoxia secondary to placental abruption following emergency caesarean section. Gestational diabetes indicated planned induction at term. At 2050 hours, antepartum haemorrhage and pat…

obstetricsmidwiferysystemcommunicationoxytocin
VIChome2013-08-23

Finding into death of Xavier Hart

4y · Male·hypoxic brain injury complicating out of hospital cardiac arrest (unknown cause)

Xavier Hart, a 4-year-old boy with obstructive sleep apnoea due to adenotonsillar hypertrophy, was found unresponsive and apnoeic at home on 21 December 2011. Despite immediate CPR and intensive resuscitation, he suffere…

paediatricsemergency medicinedelay
QLDhospital2013-07-05

Brennan, Phil John Richard

13y · Male·Staphylococcus aureus bronchopneumonia due to perinatal hypoxic-ischaemic brain …

Phil Brennan was a 13-year-old boy with severe cerebral palsy and epilepsy who died from Staphylococcus aureus bronchopneumonia. He presented with breathing difficulties one week before death; his GP examined him on 25 J…

general practicepaediatricsdiagnosticdelay
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