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WAcommunity2018-03-16

Inquest into the Deaths of Chunjun LI and Jiaolong ZHANG

42y · Male·Drowning

Two fishermen drowned after being swept into rough seas while rock fishing at Salmon Holes. Neither wore life jackets despite dangerous wave conditions. One man was retrieved deceased; the other was never found. Autopsy …

emergency medicineanaesthesiasystem
WAcommunity2018-03-16

Inquest into the Deaths of Jiaolong ZHANG and Chunjun LI

42y · Male·drowning from immersion in rough ocean waters

Two fishermen, aged 42 and 38, drowned after being swept from rocks into rough ocean at Salmon Holes near Albany, WA. Neither wore life jackets despite dangerous conditions and warning signs. Expert evidence demonstrated…

emergency medicineanaesthesia
WAhospital2018-03-15

Inquest into the Death of Roderick Leslie CARTER

63y · Male·Atherosclerotic Heart Disease

A 63-year-old farmer presented to a small rural hospital with atypical chest pain symptoms (also reporting indigestion, shivering, and numbness). Although a registered nurse appropriately triaged him as ATS 2 (high prior…

cardiologyemergency medicinecommunicationsystemaspirin
WA2018-03-08

Inquest into the Death of Moses SOKIRI

31y · Male·bronchopneumonia and hypoxic brain injury following ligature compression of the …

31-year-old Moses Sokiri died on 26 October 2014 from bronchopneumonia and hypoxic brain injury following suicide by hanging at Greenwood train station on 12 October 2014. The deceased was in acute mental health crisis w…

psychiatryemergency medicinecommunicationsystemvenlafaxine
WAhospital2018-03-07

Inquest into the Death of William Scott BARTLETT

36y · Male·hypoxic brain injury and myocardial ischaemia following cardiac arrest during re…

A 36-year-old man with methylamphetamine intoxication was restrained by civilians and police following a property damage incident. He experienced cardiac arrest during restraint and died from hypoxic brain injury and myo…

emergency medicineintensive caremethamphetamine
WA2018-02-28

Inquest into the Death of Mason Laurence CARTER and Murray Allan TURNER and Chad Alan FAIRLEY

57y · Male·immersion (drowning) - for Turner confirmed by post mortem; for Carter and Fairl…

Three fishermen died when the fishing vessel 'Returner' capsized in Nickol Bay, Western Australia on 11 July 2015. Murray Turner (57) owned and extensively modified the vessel; Chad Fairley and Mason Carter were deckhand…

occupational and environmental healthdiagnosticcommunication
WA2018-02-28

Inquest into the Death of Chad Alan FAIRLEY and Mason Laurence CARTER and Murray Allan TURNER

57y · Male·Immersion (drowning) for Murray Turner; likely immersion (drowning) for Mason Ca…

The fishing vessel Returner capsized in Nickol Bay on 11 July 2015, killing three men including experienced skipper Murray Turner (aged 57) and deckhands Chad Fairley (29) and Mason Carter (26). The vessel's catastrophic…

occupational and environmental healthdiagnosticcommunication
WA2018-02-28

Inquest into the Death of Murray Allan TURNER and Mason Laurence CARTER and Chad Alan FAIRLEY

Male·immersion (drowning) for Murray Turner; unascertained but likely immersion for C…

Three men died when the fishing vessel Returner capsized in Nickol Bay, Western Australia on 11 July 2015. The vessel had undergone extensive modifications by owner Murray Turner (age 57) without proper stability assessm…

occupational and environmental healthdiagnosticprocedural
WA2017-12-29

Inquest into the Death of Andrew Trevor HINDS and Nigel Paradine KITCHEN

50y · Male·Drowning following capsizing and disintegration of recreational fishing vessel i…

Two experienced recreational fishermen, Nigel Kitchen (50) and Andrew Hinds (57), departed Coral Bay on 29 May 2016 in a 8.2-metre vessel in deteriorating weather conditions (predicted swell 2-4 metres). Despite warnings…

WAcommunity2017-12-29

Inquest into the Death of Kyra Marjorie Carmen NARRIER

23y · Female·multiple injuries from motor vehicle collision

Ms Kyra Marjorie Carmen Narrier, a 23-year-old Indigenous woman, died on 13 November 2014 in a head-on motor vehicle collision on Thomas Road in Orelia, Perth. She was a passenger in a Hyundai Lantra driven by her partne…

methamphetamine
WAhospital2017-09-29

Inquest into the Death of Jared Charles OLSEN

41y · Male·Fulminant sepsis (Klebsiella pneumoniae) with multi-organ failure complicating s…

A 41-year-old man with newly diagnosed severe Crohn's colitis was prescribed 6-mercaptopurine (6-MP) after only 5 days of hospital treatment. He had a homozygous TPMT gene deficiency (present in ~0.3% of population) that…

gastroenterologyintensive carediagnosticsystem6-mercaptopurine
WAhome2017-09-15

Inquest into the Death of Mary Josephine Van der WALT

28y · Female·ligature compression of the neck

Mary Van Der Walt, a 28-year-old with depression, anxiety, and borderline personality disorder, died by hanging on 21 April 2014. Two police officers responding to her initial '000' call found her unresponsive and pulsel…

emergency medicineintensive carediagnosticcommunicationdesvenlafaxine
WAcommunity2017-09-06

Inquest into the Death of Mamadou Hady DIALLO

39y · Male·multiple injuries from motor vehicle collision

A 39-year-old man with chronic paranoid schizophrenia on a Community Treatment Order died by suicide in a head-on motor vehicle collision. He had been appropriately managed on depot antipsychotic medication with generall…

psychiatrygeneral practicecommunicationdiagnosticrisperidone
WAcommunity2017-09-06

Inquest into the Death of James Michael Chee Ming YUNG

42y · Male·Multiple injuries sustained in motor vehicle crash

A 42-year-old man with schizoaffective disorder subject to a Community Treatment Order died in a single-vehicle motor crash in rural Western Australia. He had poor insight, chronic medication non-adherence, and a pattern…

psychiatryemergency medicinedelaysystempaliperidone depot
WAhospital2017-08-23

Inquest into the Death of Marjorie Joy JARICK

54y · Female·Opioid toxicity (predominantly fentanyl)

54-year-old woman with diabetes, obesity, and multiple opioid allergies underwent groin surgery at a private hospital. Anaesthetist Dr Y. prescribed a 75mcg/hr fentanyl patch post-operatively for chronic pain management …

anaesthesiasurgerymedicationcommunicationfentanyl
WAhospital2017-08-22

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

0y · Male·hypoxia due to intrauterine pneumonia and haemorrhage with uterine rupture in a …

A neonate died shortly after birth from hypoxia due to intrauterine pneumonia, haemorrhage and uterine rupture following prolonged rupture of membranes during a planned vaginal birth after caesarean (VBAC). The mother at…

obstetricsneonatologycommunicationdelayoxytocin
WA2017-07-14

Inquest into the Death of Maung PU

49y · Male·bronchopneumonia

49-year-old male seaman died of bronchopneumonia with secondary pericarditis on a cargo vessel 30 nautical miles off Port Hedland. He developed acute abdominal pain and vomiting on 29 September 2012 and deteriorated rapi…

emergency medicineretrieval medicinediagnosticdelayparacetamol
WAhospital2017-07-11

Inquest into the Death of Beasley (also known as Graeme Leslie Syme)

49y · Male·Complications of penetrating sharp force injuries through the chest and abdomen …

Graeme Leslie Syme (Beasley), a 49-year-old male on parole with methamphetamine use history, died from penetrating chest and abdominal stab wounds he self-inflicted. Key clinical lessons: his case involved self-harm foll…

emergency medicinetrauma surgerysystemdelaymethamphetamine
WAhome2017-06-29

Inquest into the Death of Ejub MEHINOVIC

50y · Male·coronary artery atherosclerosis causing sudden fatal cardiac arrhythmia

Ejub Mehinovic, a 50-year-old man with treatment-resistant paranoid schizophrenia managed on clozapine, died from coronary artery atherosclerosis causing sudden fatal cardiac arrhythmia. He was under a Community Treatmen…

psychiatrygeneral practicedelayclozapine
WAmental health2017-06-22

Inquest into the Death of Annette SILVER

47y · Female·Multiple injuries from being struck by a train

A 47-year-old woman with major depressive disorder and anxiety died by suicide while an involuntary psychiatric inpatient. She had attempted suicide in November 2014 and was admitted to Bentley Hospital for psychiatric t…

psychiatrypsychologysupervisionsystemcitalopram
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