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QLD2017-02-10

Sloan, Dane Benjamin

24y · Male·Hypoxic ischaemic encephalopathy due to or as a consequence of being hanged

Dane Benjamin Sloan, a 24-year-old remand prisoner with mental health history including suicidal ideation, hanged himself in the Maximum Security Unit exercise yard at Brisbane Correctional Centre. Although CCTV monitore…

psychiatryemergency medicinesystemdelayamitriptyline
QLDcommunity2017-02-10

Haimona, Elliot Arapita

23y · Male·stab wounds to the neck

Elliot Haimona, aged 23, died from extensive self-inflicted stab wounds to the neck sustained during a sudden act of self-harm. He stabbed himself repeatedly with a kitchen knife while visiting a friend's motel unit. Pol…

cannabis
QLDhome2017-02-07

ES, a 87 year old lady

87y · Female·Multiple opioid drug toxicity (morphine and fentanyl) in combination with conges…

An 87-year-old woman with multiple comorbidities (ischaemic heart disease, emphysema, chronic kidney disease) was discharged home for palliative care after a hospital admission. Her family administered excessive doses of…

general practicepalliative caremedicationcommunicationmorphine
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
QLDcommunity2016-12-08

Floyd, Leah Elizabeth

48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…

A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …

neurologypsychiatrycommunicationsystemdiazepam
QLDhome2016-11-30

LAMH - non-inquest findings

31y · Female·Mixed drug toxicity

A 31-year-old woman with long-standing opioid dependence enrolled in the Queensland Opioid Treatment Program died from mixed drug toxicity, with toxic levels of Fentanyl and other drugs in her system. A general practitio…

general practiceemergency medicinemedicationdiagnosticfentanyl
QLDcommunity2016-11-28

Toms, Trevor Lewis - Non-inquest findings

47y · Male·Multiple injuries due to or as a consequence of a motor vehicle accident

Trevor Toms, 47, died in a head-on motor vehicle collision after driving at speed on the wrong side of a rural highway. He had epilepsy managed with sodium valproate but had experienced multiple seizures in the months be…

general practiceneurologydiagnosticcommunicationsodium valproate
QLDhospital2016-11-23

SPB - Non-inquest findings

36y · Male·hanging

A 36-year-old man with 15-year history of paranoid schizophrenia and polysubstance abuse presented to hospital after violent behaviour toward his father while intoxicated. Despite police concerns, family requests for adm…

psychiatryemergency medicinediagnosticcommunicationdiazepam
QLDhospital2016-11-14

Ms H - non-inquest findings

23y · Female·Necrotising retroperitoneal fasciitis due to acute perforated gangrenous appendi…

Ms H, a 23-year-old with Asperger's syndrome and intellectual impairment under OPG guardianship for healthcare decisions, presented to Redcliffe Hospital ED with abdominal pain, vomiting and diarrhoea. Despite clinical c…

emergency medicinesurgerysystemdiagnosticparacetamol
QLDhospital2016-11-07

Bower, Malaki Ron - Non-inquest findings

2y · Male·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest secondary to up…

A 2-year-old boy presented to hospital with croup (parainfluenza 1 laryngotracheobronchitis) on 13 July 2013. He was given nebulised adrenaline by ambulance and dexamethasone at hospital, then discharged after only 3 hou…

emergency medicinepaediatricsdiagnosticcommunicationnebulised adrenaline
QLDhospital2016-11-04

Neitsch, Horst - non-inquest findings

77y · Male·Stroke; cardiogenic shock; severe aortic stenosis with three vessel coronary art…

Mr Neitsch, a 77-year-old with severe aortic stenosis, peripheral vascular disease, and reduced left ventricular function, underwent elective coronary angiography at Princess Alexandra Hospital on 21 May 2015. The proced…

cardiologyvascular surgeryproceduralcommunicationfurosemide
QLDcommunity2016-11-01

Ms D - Non-inquest findings

47y · Female·Cardiorespiratory failure precipitated by multiple rib fractures rendering the c…

Ms D, aged 47, was struck and killed by a motor vehicle at a public park on 13 February 2016. The vehicle rolled downhill after the owner engaged only a partially effective handbrake (at the 6th ratchet position instead …

QLDcommunityPodcast2016-10-27

Walton, Christopher Jon

54y · Male·multiple injuries due to or as a consequence of being crushed by the falling awn…

Christopher Walton, aged 54, died on 23 December 2012 when an awning collapsed on him in Burleigh Heads, Queensland. The 35-year-old awning was attached to the building using inadequate torque-controlled expansion anchor…

designsystem
QLDhospital2016-10-25

Hemsley, Joanne - non-inquest findings

55y · Female·Cardiac tamponade due to haemopericardium due to acute ruptured myocardial infar…

A 55-year-old woman with extensive coronary artery disease presented for elective stent placement to her left anterior descending artery. During the procedure, a small diagonal branch vessel was occluded—a recognised com…

cardiologycardiothoracic surgerydiagnosticcommunicationticagrelor
QLDhospital2016-09-15

Mr B, a 41 year old indigenous man - Non-inquest findings

41y · Male·Subdural haematoma

A 41-year-old Aboriginal man with excessive alcohol use presented four times to a rural hospital over one month with headaches. His symptoms were attributed to cluster migraine, then alcohol withdrawal syndrome, despite …

emergency medicineneurologydiagnosticcommunicationdiazepam
QLDcommunity2016-09-10

C, a child aged 14 - Non-inquest findings

14y · Female·Hypoxic-ischaemic encephalopathy due to choking on food, as a consequence of foe…

A 14-year-old girl with foetal alcohol syndrome, autism, and intellectual impairment died from hypoxic-ischaemic encephalopathy following choking on food during a community outing. She had been in state care since infanc…

paediatricsemergency medicinesystemcommunication
QLDhospital2016-09-02

Calder, Michael James

33y · Male·Opiate toxicity

A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both slow-release (MS Co…

general medicineemergency medicinemedicationdiagnosticmorphine
QLDhome2016-08-26

Winbank, Leslie Geoffrey

53y · Male·Self-inflicted gunshot wound to the head

Leslie Winbank, a 53-year-old man with chronic pain from disc prolapse and prostate cancer, died from a self-inflicted gunshot wound during a police siege at his home. He had a family relationship breakdown and was on pa…

psychiatrypain medicineoxycodone
QLDhome2016-08-22

SJM - Non-inquest findings

57y · Male·Mixed drug toxicity, predominantly propoxyphene (Doloxene)

A 57-year-old man died from mixed drug toxicity, predominantly propoxyphene (Doloxene), combined with benzodiazepines. His GP of 13 years prescribed Doloxene for 10 years despite documented alcohol abuse history, which w…

general practicepathologymedicationdiagnosticpropoxyphene
QLDhospital2016-08-19

Plumb, Mark Anthony

76y · Male·Multiple organ failure due to sepsis with peritonitis and pancreatitis, secondar…

A 76-year-old man died from multiple organ failure following an ERCP procedure for gallstone removal. The procedure itself was appropriate and uneventful. Post-operatively, he developed severe abdominal pain and a CT sca…

surgeryanaesthesiadiagnosticcommunicationmorphine
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