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WAhospital2019-04-04

Inquest into the Death of Maris KUGIS

68y · Male·Bronchopneumonia in a man with chronic obstructive pulmonary disease

Maris Kugis, a 68-year-old man with chronic schizophrenia, personality disorders, and multiple serious physical conditions including COPD, ankylosing spondylitis, and undiagnosed pancreatic adenocarcinoma, died from bron…

psychiatryrespiratory medicinehaloperidol
WAhospital2019-03-12

Inquest into the Death of Lorna May WOODS

39y · Female·pulmonary thromboembolism due to deep vein thrombosis and sepsis due to pyelonep…

Lorna May Woods, 39, died from pulmonary thromboembolism due to deep vein thrombosis and sepsis secondary to pyelonephritis on a background of metastatic ovarian cancer. She presented to Joondalup Health Campus with uros…

emergency medicinepsychiatryheparin
WAhospital2019-03-08

Inquest into the Death of Seanpol Martin Padraig O'NEILL

30y · Male·methadone toxicity

A 30-year-old man with schizoaffective disorder, narcolepsy, and obesity died from methadone toxicity while an involuntary psychiatric patient. He was prescribed multiple sedating medications including methadone, benzodi…

psychiatryemergency medicinecommunicationsystemmethadone
WA2019-02-15

Inquest into the Death of Henrick OOSTERBAAN

64y · Male·Unknown - coroner made no finding as to cause of death

A 64-year-old man disappeared in January 2017 after learning of a police investigation into historical child sexual abuse allegations. He left a note indicating his intention to end his life in a remote area near Menzies…

WAcommunity2019-02-07

Inquest into the 13 Deaths of Children and Young Persons in the Kimberley Region

Ligature compression of the neck (hanging) in 12 cases; one open finding

This complex coronial inquest examined 13 Aboriginal children and young persons who died by suicide in the Kimberley Region between 2012–2016. The coroner found 12 deaths were suicides and one open finding. Common contri…

psychiatrypaediatricsdiagnosticcommunicationalcohol
WA2019-02-06

Inquest into the Death of William John DAVIS

37y · Male·Subarachnoid haemorrhage due to ruptured berry aneurysm of the right middle cere…

A 37-year-old male prisoner with Ehlers-Danlos Syndrome died from subarachnoid haemorrhage due to a ruptured berry aneurysm at Karnet Prison Farm. He collapsed suddenly while appearing well minutes earlier. The coroner f…

psychiatryneurology
WAcommunity2019-02-06

Inquest into the Death of Torran Jake THOMAS

15y · Male·Multiple organ failure associated with hyperthermia (heat stroke)

A 15-year-old rugby league player died from heat stroke during training on an extremely hot Perth summer evening (44.4°C). The coaching staff appropriately applied NRL heat guidelines in deciding to proceed with modified…

emergency medicineintensive carediagnosticdelay
WAcommunity2019-01-29

Inquest into the Death of Glenn William STRICKLAND

43y · Male·Complications of neck injury; specifically extensive brainstem infarction second…

Glenn William Strickland, an experienced Harley Davidson rider, died from brainstem infarction following severe cervical spinal injury sustained in a motorcycle crash on Julimar Road, Western Australia. He failed to nego…

emergency medicinetrauma surgerysystemdelay
WA2019-01-07

Inquest into the Death of Ali JAFFARI

Male·thermal injuries (burns)

Ali Jaffari, an immigration detainee, died by suicide at Yongah Hill Immigration Detention Centre on 16 September 2015. He sustained fatal thermal injuries from a fire he deliberately started in his room. The deceased ha…

psychiatrypsychologysystemolanzapine
WA2018-12-27

Inquest into the Death of Mohammad Nasim NAJAFI

24y · Male·seizure (epileptic)

Mohammad Nasim Najafi, a 24-year-old Afghan detainee with well-controlled epilepsy, died from a seizure after missing multiple doses of carbamazepine in the days preceding his death. He was held in immigration detention …

neurologygeneral practicesystemdelaycarbamazepine
WAcommunity2018-12-12

Inquest into the Death of Joseph Frederick WOODS

34y · Male·cardiorespiratory arrest during struggle and restraint in a man with methylamphe…

A 34-year-old man with methylamphetamine intoxication (blood level 1.2 mg/L) and focal coronary artery atherosclerosis died from cardiorespiratory arrest during a struggle and restraint by a homeowner and subsequent poli…

toxicologycardiologymethamphetamine
WAhome2018-12-06

Inquest into the Death of Mark Leslie SACH

27y · Male·combined drug toxicity (U-47700 and etizolam)

Mark Sach, aged 27, died from combined drug toxicity involving U-47700 (a synthetic opioid 7.5 times more potent than morphine) and etizolam (a benzodiazepine 10 times more potent than diazepam), obtained via internet pu…

pain medicinegeneral practicecommunicationdelayu-47700
WAhome2018-10-23

Inquest into the Death of Lorraine Jane HANSEN

25y · Female·Head injuries

Lorraine Jane Hansen, 25, died from head injuries on 29 June 2016 after being found on a roadway in Willetton, Western Australia. She had been involved in a chaotic social gathering with alcohol, arguments, and physical …

systemalcohol
WAhospital2018-10-12

Inquest into the Death of Augustinus Clemens Antonius HEESTERS

70y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis

A 70-year-old sentenced prisoner with severe ischaemic heart disease and prior myocardial infarctions died from acute myocardial infarction with coronary artery atherosclerosis. He presented with severe chest pain on 5 O…

cardiologyemergency medicinesystemaspirin
WAhome2018-09-21

Inquest into the Death of Pamella Leslie REES

63y · Female·disseminated metastatic carcinoma of unknown primary in a woman with multiple sc…

Pamella Rees, a 63-year-old woman with longstanding multiple sclerosis, died on 30 June 2014 from disseminated metastatic carcinoma of unknown primary. Her cancer went undiagnosed despite regular GP contact. In her final…

general practiceneurologydiagnosticcommunicationcodeine
WAcommunity2018-09-20

Inquest into the Death of Scott Andrew BLANCHARD

45y · Male·Gunshot injury to the chest (self-inflicted)

Scott Andrew Blanchard, a 45-year-old Detective Sergeant with the Western Australian Police Gang Crime Squad, died from a self-inflicted gunshot wound while on duty near Kalgoorlie. In June 2015, following a trip to Thai…

psychiatryemergency medicinecommunication
WAmental health2018-09-19

Inquest into the Death of Wlodzimierz DUDEK

69y · Male·bronchopneumonia and hypoxic brain injury following aspiration of food (choking)

A 69-year-old male with bipolar affective disorder and suspected frontotemporal dementia, admitted involuntarily to a psychiatric hospital, choked on bread while eating breakfast unattended and suffered a cardiac arrest.…

psychiatryemergency medicinecommunicationsystem
WAhospital2018-09-10

Inquest into the Death of Theodore Herbert Eric JOHANSEN

50y · Male·Drowning

Theodore Johansen, a 50-year-old man with a history of anxiety and depression, presented to his GP on 28 October 2014 with active suicidal ideation and a detailed plan to drown himself using a block and chain. He was app…

psychiatryemergency medicinediagnosticcommunicationamitriptyline
WAhospital2018-08-23

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

0y · Unknown·Mechanical asphyxiation as a consequence of overlaying

Baby A, a 7-week-old premature infant, died from mechanical asphyxiation due to overlaying while co-sleeping with his mother at Derby Hospital. The baby had been transferred from Darwin Hospital for weight monitoring and…

neonatologymidwiferycommunicationsystem
WA2018-08-17

Inquest into the Death of Jeffery Thomas DOYLE

61y · Male·Unknown, but probably immersion (drowning)

A 61-year-old experienced recreational boat skipper died after his vessel became disabled by ropes fouling the propellers while fishing off the Western Australian coast. He likely entered the water to clear the obstructi…

proceduralcommunication
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