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WAmental health2005-08

Inquest into the Death of Ward

44y · Male·Ligature compression of the neck (hanging)

Geoffrey Stephen Ward, a 44-year-old involuntary psychiatric patient at Graylands Hospital with chronic paranoid schizophrenia, died by hanging on 20 February 2000. He had been progressing well on antipsychotic medicatio…

psychiatryforensic medicineolanzapine
NTcommunity2005-07-19

Inquest into the death of Carlene Coombe

43y · Female·stab wound to the chest; contributing factors were aspiration of stomach content…

A 43-year-old Aboriginal woman died from a stab wound to the chest in circumstances that remain unclear. She had a complex history of depression, alcohol dependence, and family crisis (children removed from her care). Sh…

forensic medicinegeneral practicealcohol
QLD2005-07-08

Pugh, Samuel

46y · Male·Cardiac failure due to blood loss from traumatic laceration to right thigh susta…

Samuel Pugh, a 46-year-old mining contractor, died from cardiac failure due to blood loss after being struck by a 219 kg falling rock underground at a Queensland mine. He suffered a severe laceration to his right thigh w…

occupational and environmental healthemergency medicinecommunicationsystem
NTcommunity2005-06-09

Inquest into the death of Albert Robbo

35y · Male·Multiple injuries resulting from a motor vehicle accident in which the deceased …

Albert Robbo, a 35-year-old Aboriginal man, died from multiple injuries after being run over by a police vehicle while sleeping under a shelter on 5 February 2004. The police 4WD was conducting a routine patrol in respon…

proceduralsystem
ACTcommunity2005-06-08

Inquest Into The Manner And Cause Of Death Of Jamie Vincent Johnson

20y · Male·diffuse cerebral oedema caused by hyponatraemia caused by excessive self-induced…

Jamie Johnson, 20, was intellectually disabled and lived in supported accommodation with carers. In June 2000, he was admitted with severe hyponatraemia and seizure from excessive water drinking (psychogenic polydipsia).…

neurologypsychiatrycommunicationsystem
SAhospital2005-06-03

Coroner's Finding: SORENSEN Ruth Bengta Maria

69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…

A 69-year-old woman presented to the Emergency Department with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood t…

emergency medicinesurgerydiagnosticcommunicationprochlorperazine
SAhospital2005-06-02

Coroner's Finding: GREEN Marie

64y · Female·Respiratory arrest secondary to morphine overdosage on a background of mild to m…

A 64-year-old woman died from respiratory arrest secondary to morphine overdose after ingesting 17 tablets of slow-release morphine (Kapanol) and diazepam. Initial emergency assessment by an intern was appropriate, but c…

emergency medicinegeneral medicinecommunicationdiagnosticmorphine
SAhospital2005-06-02

Coroner's Finding: HUTCHINSON Matthew

0y · Male·cardiogenic shock and neonatal encephalopathy

Matthew Hutchinson, born at 1 day of age at Flinders Medical Centre, died from cardiogenic shock and neonatal encephalopathy. While obstetric care was appropriate, neonatal care was significantly deficient. Critical fail…

neonatologyobstetricsproceduralcommunicationphenobarbital
SAprison2005-05-31

Coroner's Finding: McLEOD Ian

45y · Male·bronchopneumonia and suppurative bronchitis complicating hypoxic brain damage

Ian McLeod, a 45-year-old lawyer with alcohol dependence and depression, died from hypoxic brain damage and bronchopneumonia following a hanging while in custody at Yatala Labour Prison. Multiple system failures contribu…

psychiatrycorrectional healthdiagnosticcommunicationdiazepam
SAhospital2005-05-24

Coroner's Finding: WALLACE-MOHLMANN Candice Mackenzie

30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…

Candice Mackenzie Wallace-Mohlmann, a 30-year-old woman with chronic schizophrenia and substance abuse history, died from hypoxic brain injury caused by self-injection of vecuronium and atropine obtained from a hospital …

psychiatryemergency medicinediagnosticmedicationvecuronium
WAhospital2005-05-16

Inquest into the Death of Sweet

90y · Female·Intracerebral haemorrhage

Zenobia Enid Sweet, a 90-year-old woman with mild dementia, was admitted to Sir Charles Gairdner Hospital in April 2002 for surgical repair of a fractured femur. She was rehabilitating on Ward G51 (orthopaedics) with a g…

orthopaedic surgeryphysiotherapysystemcommunication
QLDhospital2005-05-04

Robinson, Jacinta Kate

7y · Female·cardiac tamponade due to total parenteral nutrition fluid leakage into the peric…

A 7-year-old girl with spina bifida died from cardiac tamponade caused by total parenteral nutrition (TPN) fluid leaking into the pericardial sac via a central venous line inserted during bowel obstruction surgery. Clini…

paediatric surgeryanaesthesiadiagnosticcommunicationtotal parenteral nutrition
WAhospital2005-05-04

Inquest into the Death of Michael Anderson

0y · Male·Sequelae of drug toxicity (poisoning) — specifically respiratory depression and …

Michael Anderson was a 9-day-old Aboriginal infant who collapsed at King Edward Memorial Hospital on 15 November 2000 after being administered a gross overdose of paracetamol and codeine (likely via crushed panadeine for…

neonatologypaediatricscommunicationdelayparacetamol
WAhome2005-05-01

Inquest into the Death of Christopher Nigel Spinks

35y · Male·Acute Staphylococcus aureus Meningitis

Christopher Nigel Spinks, a 35-year-old tree surgeon, died of acute Staphylococcus aureus meningitis on 3 December 2002. He initially presented on 27 November 2002 with neck pain following a windsurfing accident. Dr R. n…

general practiceemergency medicinediagnosticdelaynurofen plus
WAhospital2005-05

Inquest into the Death of Olivia ("Peta") Dawson

26y · Female·Asphyxiation due to Ligature Compression of Neck

Peta Dawson, a 26-year-old woman with a history of depression, self-harm, and suicidal ideation following miscarriage and maternal rejection, was admitted to Merredin Hospital on 10 August 2003 after presenting with wris…

emergency medicinepsychiatrysystemdelaykalma
WAcommunity2005-05

Inquest into the Death of Adam David McKay

31y · Male·Pulmonary thromboembolism arising from deep vein thrombosis

Adam David McKay, a 31-year-old geologist, died from pulmonary thromboembolism arising from deep vein thrombosis on 23 January 2003. He had recently completed extensive long-haul flights to West Africa and returned on 13…

general practiceemergency medicinediagnosticcommunication
SA2005-04-11

Coroner's Finding: POTTER Claire Elizabeth

26y · Female·multiple injuries sustained as a result of being struck by a motor vehicle on th…

A 26-year-old woman with schizo-affective disorder, detained under the Mental Health Act, absconded from a psychiatric hospital and was fatally struck by a vehicle on a freeway. Clinical concerns include: (1) inadequate …

psychiatryemergency medicinecommunicationsystemolanzapine
QLDpolice custody2005-04-07

Hope Vale man

27y · Male·asphyxia caused by self-inflicted hanging

A 27-year-old Aboriginal man died by hanging in the back of a community police van whilst being transported from Hope Vale to Cooktown after arrest for domestic violence. Three community police officers with minimal trai…

forensic medicinecorrectional healthproceduralsystemalcohol
NThospital2005-04-06

Inquest into the death of Peter Wiryal

48y · Male·Cerebrovascular Accident (stroke) caused by subdural haemorrhage, which resulted…

Peter Wiryal, 48, was struck by a white van driven by an intoxicated Daniel Johnson along George Crescent, Fannie Bay at approximately 12:30am on 4 April 2003. He was discharged from Royal Darwin Hospital on 4 April afte…

emergency medicineneurosurgerydiagnosticcommunicationalcohol
WAhospital2005-04

Inquest into the Death of Kevin Gregory Quartermaine

36y · Male·Ischaemic Heart Disease and Severe Multifocal Coronary Atherosclerosis in a man …

Kevin Gregory Quartermaine, a 36-year-old Aboriginal man and sentenced prisoner at Casuarina Prison, died from ischaemic heart disease with severe multifocal coronary atherosclerosis on 17 May 2002. He had extensive coro…

cardiologyintensive careinsulin

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