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QLDaged care2016-05-03

Thomas, Florence Lillian - Non-inquest findings

85y · Female·neck injury (cervical spine fracture) as a consequence of a fall

Mrs Florence Thomas, 85, died from cervical spine fractures sustained when she fell from a toilet chair at her nursing home. She had multiple documented falls and explicit care plan instructions never to be left alone on…

geriatric medicineemergency medicinesystemcommunication
QLDcommunity2016-04-20

Newport, Glenn Richard

38y · Male·cardiac arrest precipitated by dilutional hyponatraemia

A 38-year-old construction worker died from dilutional hyponatraemia after working in extreme heat (>40°C) on a concrete formwork project in rural Queensland. He developed symptoms of heat injury at the worksite and was …

occupational and environmental healthparamedicinediagnosticcommunication
QLDhome2016-04-07

Corben, William Chase

4y · Male·Drowning

William Corben, a 4-year-old non-swimmer with documented chlorine reaction, drowned in neighbours' backyard pool on 28 February 2015 after approximately 20-27 minutes without oxygen. Critical factors included: pool gates…

supervisionsystem
QLDhome2016-04-04

Cwaczko, Xaviyah Dre - Non-inquest findings

3y · Male·Hypoxic ischaemic encephalopathy as a consequence of near drowning

A 3-year-old non-swimmer, Xaviyah Cwaczko, drowned while in the overnight care of a family friend. He gained unsupervised access to an in-ground swimming pool when a safety gate was deliberately propped open with a metal…

systemdelay
QLD2016-03-21

PB - Non-inquest findings

55y · Male·Traumatic asphyxia following compression of lower chest and upper abdomen

A 55-year-old experienced transport worker died from traumatic asphyxia when a car carrier trailer he was servicing lowered unexpectedly, trapping him underneath. While replacing an airbag, he inadvertently dislodged a m…

QLDhospital2016-03-18

McGuane, Shirley Fay - Non-inquest findings

84y · Female·Myocardial infarction

Shirley McGuane, 84, died from myocardial infarction following elective proctocolectomy. Post-operative care was deficient: chest pain on day 2 post-op with ECG showing atrial fibrillation and new right bundle-branch blo…

surgerycardiologydiagnosticcommunicationwarfarin
QLDcommunity2016-03-17

Koefer, Nelani Ciara

4y · Female·drowning due to uncontrolled release of water from ruptured rubber dam

Four-year-old Nelani Koefer drowned when a rubber dam on the Bedford weir catastrophically failed, releasing an uncontrolled wall of water. The dam had been defectively manufactured with hairline cracks in the inner memb…

systemdelay
QLD2016-03-10

Kelley, Reuben George - Non-inquest findings

18y · Male·Multiple injuries due to motor vehicle collision

An 18-year-old provisional driver died in a motor vehicle collision after driving at 120-130 kph in a 60 kph zone on a wet road with intermittent rain. He lost control on an incline, became airborne, and struck a power p…

QLDhospital2016-02-29

Mr B - Non-inquest findings

84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…

An 84-year-old man with multiple comorbidities was prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed,…

cardiologyhaematologymedicationcommunicationrivaroxaban
QLDworkplace2016-02-29

MJP - Non-inquest findings

27y · Female·Pentobarbitone toxicity

A 27-year-old veterinary nurse with a 5-year history of depression died from pentobarbitone toxicity self-administered at her workplace. She had two previous suicide attempts (2010, 2011) both involving alcohol. On the e…

general practicepsychiatrysystemcommunicationpentobarbitone
QLDhospital2016-02-22

Robertson, Elsie - Non-inquest findings

0y · Female·Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, s…

Elsie Robertson was a preterm neonate born at 30 weeks gestation from a monochoroidal diamniotic twin pregnancy complicated by Twin-to-Twin Transfusion Syndrome (TTTS) treated with laser photocoagulation at 23 weeks. She…

obstetricsneonatologycommunicationsystemmagnesium sulphate
QLDhospital2016-02-17

Dickinson, Rick Dudley

55y · Male·Cardiac tamponade due to ruptured aortic dissection (Type A) against a backgroun…

Rick Dickinson, a 55-year-old man, presented to St Andrew's War Memorial Hospital after experiencing severe central chest pain and lower back pain with numbness at the gym. The treating senior doctor failed to adequately…

emergency medicinepathologydiagnosticcommunicationmorphine
QLD2016-02-12

A - Non-inquest findings

Unknown·Multiple injuries due to a motor vehicle accident

A died in a motor vehicle collision on the Bruce Highway in wet conditions. The vehicle aquaplaned after the front left tyre was fitted in the incorrect direction of rotation, substantially reducing wet weather performan…

amphetamine
QLDhome2016-02-09

DM

35y · Female·Stab wound to chest penetrating the descending thoracic aorta resulting in catas…

DM, a 35-year-old woman, died from a stab wound to the chest inflicted by her husband during a domestic violence incident on 26 June 2011. The wound penetrated the descending thoracic aorta, causing catastrophic blood lo…

forensic medicineemergency medicinesystemcommunicationamphetamine
QLDcommunity2016-02-05

Cooper, Paul James - Non-inquest findings

41y · Male·Hanging

Paul Cooper, a 41-year-old man with bipolar disorder, died by hanging in August 2015, eleven days after psychiatric review. He had recently commenced Isotretinoin for severe acne, which coincided with development of para…

psychiatrygeneral practicecommunicationsystemisotretinoin
QLDPodcast2016-02-05

Edwards, Sean Lawrence Guy

26y · Male·Multiple injuries sustained in motor vehicle collision

Sean Edwards, a professional racing driver aged 26, died as a passenger during a coaching session at Queensland Raceway when the vehicle experienced total mechanical brake failure approaching Turn 6 at approximately 165 …

diagnosticsystem
QLD2016-01-19

Adams, Jamie Christopher; Watkins, Gary Robert - Non-inquest findings

Male·Multiple injuries as a result of being struck by a Track Machine in a railway in…

Two Queensland Rail workers died when struck by a track machine while performing railway maintenance at Mindi in December 2007. The Coroner identified multiple contributing factors: defective lighting on the machine, ina…

communicationprocedural
QLDhospital2016-01-19

Mott, Melvin Thomas

71y · Male·Invasive bladder cancer (urothelial carcinoma)

A 71-year-old male prisoner presented with lower abdominal pain and was found to have invasive bladder cancer (urothelial carcinoma). Diagnosis occurred within 12 days of symptom onset through CT imaging and biopsy. Radi…

urologyradiation oncology
QLDhospital2016-01-19

McCart, Thomas Gerard

55y · Male·Renal cell carcinoma (brain metastasis)

A 55-year-old man on remand was found confused and disoriented upon reception to correctional custody on 16 September 2014. He was appropriately transferred to hospital where MRI imaging revealed a large right frontal br…

neurosurgeryneurology
QLD2016-01-19

Reynolds, Michael John

55y · Male·coronary atherosclerosis

Michael Reynolds, aged 55, died of coronary atherosclerosis while incarcerated. He had suffered a myocardial infarction at age 32 and subsequently refused cardiac medications despite medical advice, a decision consistent…

cardiologyforensic medicinesodium valproate
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