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SA2006-05-22

Coroner's Finding: GEORGE Patricia Nina

81y · Female·aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphy…

Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive heart failure. A critical ambulance transfer delay …

psychiatryemergency medicinecommunicationsystemsalbutamol
SAhospital2006-05-19

Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…

77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural ta…

cardiologycardiothoracic surgerydiagnosticproceduralramipril
QLD2006-05-19

Marshall, Peter Whitoria

Male·Crush injuries sustained when struck by and pinned under a heavy truck wheel as …

Peter Marshall, a senior tyre fitter at a Queensland zinc mine, died from crush injuries after being struck by a 3.5-tonne truck wheel that was explosively released during maintenance. The fatal incident resulted from a …

proceduralcommunication
SAhospital2006-05-18

Coroner's Finding: PAHL-CADMAN Emma Rose

20y · Female·cardiac dysrhythmia/arrest in a 20 year old Down's Syndrome female following abd…

A 20-year-old woman with Down syndrome and Eisenmenger syndrome (cyanotic heart disease with ventricular septal defect) was admitted with abdominal obstruction. After appropriate diagnostic workup, laparotomy was perform…

general surgeryanaesthesiadiagnosticcommunication
QLDcommunity2006-05-15

Baker, Rodney John

Male·Drowning resulting from capsizing of trawler

Rodney John Baker, an experienced trawler skipper, died when his 51-foot steel trawler Gulf Stream capsized in stormy conditions off Cape Moreton, Queensland on 29 January 2004 while attempting to haul nets that had caug…

SAhospital2006-05-12

Coroner's Finding: MARTIN Kirsten Lee

24y · Female·multi organ failure due to meningococcal septicaemia

24-year-old woman presented to ED with fever (40.1°C), headache, myalgia and mild photophobia. RMO Dr R., relatively inexperienced (5 weeks in Australia), examined her thoroughly but focused on excluding meningitis throu…

emergency medicineinfectious diseasesdiagnosticcommunication
SAhome2006-05-05

Coroner's Finding: KILEY Carol Anne

55y · Female·Multiple drug toxicity due to combination of alcohol and benzodiazepines (oxazep…

Carol Anne Kiley, a 55-year-old woman with chronic back pain, depression, and likely alcohol dependence, died from multiple drug toxicity involving alcohol, oxazepam (toxic level), temazepam, and promethazine. Her GP, Dr…

general practicepsychiatrymedicationdiagnosticoxazepam
NTcommunity2006-05-04

Inquest into the death of Cynthia Diane Ching

29y · Female·multiple organ failure following persistent sepsis occurring as a complication o…

Cynthia Diane Ching, a 29-year-old Canadian visitor, sustained severe burns (60% of body) on 15 April 2004 when aviation fuel from a makeshift lantern was spilled onto her by one of two helicopter pilots at Kings Creek S…

plastic and reconstructive surgeryintensive careproceduralsystemmorphine
SA2006-04-28

Coroner's Finding: WALKER Darryl Kym

31y · Male·hanging (self-inflicted)

Darryl Walker, a 31-year-old Aboriginal man with chronic schizophrenia and diabetes, died by hanging in Port Lincoln Prison on 2 June 2003. He had been transferred to an isolated management unit (Unit 7) on 1 June after …

psychiatrygeneral practicediagnosticcommunicationchlorpromazine
NThospital2006-04-28

Inquest into the death of Zena Stevens

2y · Female·septicaemia

Zena Stevens, a 2.5-year-old Aboriginal girl, died from septicemia at Tennant Creek Hospital on 14 January 2005. She had presented to clinic on 11 January with fever, purulent ears and a recently lanced abscess after rec…

paediatricsemergency medicinediagnosticcommunicationprocaine penicillin
QLD2006-04-26

Karajic, Scott Meho

Male·Multiple crush injuries to the upper chest and neck sustained in a drilling rig …

Scott Karajic died when a stand of drill collars fell through a stabbing mat and crushed him against a mouse hole on a gas drilling rig at Berwyndale South on 28 February 2003. Despite comprehensive safety policies and a…

systemprocedural
SAhospital2006-04-21

Coroner's Finding: EDWARDS Ruby Mabel

77y · Female·haemorrhagic diathesis due to warfarin toxicity

Ruby Mabel Edwards, 77, died from haemorrhagic diathesis due to warfarin toxicity after 84 days in a rural hospital. She had a prosthetic aortic valve requiring anticoagulation. INR monitoring was inadequate: no tests fo…

general practicehaematologymedicationdelaywarfarin
QLD2006-04-13

Adams, Michael James

20y · Male·Hanging (wilful murder by Andrew Thomas Kranz)

Michael James Adams, aged 20, died by hanging in prison on 11 September 1997. He was placed in Unit 7B at Sir David Longland Correctional Centre despite documented concerns from medical and correctional staff about his s…

systemdelayheroin
QLD2006-04-07

Meech, Paul Andrew

40y · Male·Asphyxia caused by a seizure resulting from severe alcohol intoxication. Underly…

Paul Meech, a 40-year-old man with bipolar affective disorder, died of asphyxia caused by a seizure from severe alcohol intoxication while in police custody at Hervey Bay watch house. Critical failures occurred: (1) The …

psychiatryemergency medicinediagnosticcommunicationhaloperidol
WAcommunity2006-03-24

Inquest into the Death of Tarah Anne Basiak

12y · Female·Crush Asphyxia with Vomit Aspiration

Tarah Anne Basiak, aged 12, died on 19 June 2004 when a utility vehicle she was riding on rolled over while being driven by an inexperienced teenage driver on a private property near Baldivis, Western Australia. Tarah wa…

NTcommunity2006-03-22

Inquest into the death of Dolly Granites

70y · Female·fungal pneumonia as a complication of breast cancer and its treatment

Dolly Granites, a 70-year-old Aboriginal woman, died from fungal pneumonia complicating breast cancer in September 2004. A significant 17-month delay occurred between initial detection of a breast lump in October 2002 an…

general practiceoncologysystemcommunication
QLD2006-03-17

Smith, David Edward

21y · Male·Multiple stab wounds inflicted by Andrew Kranz who was assisted in the murder by…

David Edward Smith, 21, was murdered in prison by inmates with 31 stab wounds after being forcibly moved to a high-risk unit despite clear and repeated warnings of danger. Staff ignored his requests for protection and fa…

correctional healthcommunicationsystem
QLD2006-03-16

Schumacher, Nicholas

15y · Male·Head injury

A 15-year-old naval cadet, Nicholas Schumacher, died from head injuries sustained in a vehicle rollover on 12 September 2004. The vehicle, a 1983 Toyota LandCruiser carrying eight cadets, experienced sudden deflation of …

proceduralsystem
NT2006-03-03

Inquest into the death of Muhammad Heri

37y · Male·Coronary Atherosclerosis

Muhammad Heri, a 37-year-old Indonesian fisherman, died from coronary atherosclerosis while detained in Darwin Harbour on 28 April 2005. He had been held on his fishing vessel for 7 days without medical examination follo…

forensic medicineemergency medicinesystemdelay
WA2006-03

Inquest into the Death of Leon John Donaldson

20y · Male·Ligature compression of the neck (hanging)

Leon John Donaldson, a 20-year-old sentenced prisoner with a documented history of self-harm, depression, and suicidal ideation, died by hanging in his cell at Casuarina Prison on 2 September 2004. He had been identified…

psychiatrypsychologysystemcommunicationsodium valproate

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