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NThome2005-03-29

Inquest into the death of Marshall Yantarrnga

37y · Male·Coronary artery thrombosis resulting from coronary atherosclerosis with contribu…

Marshall Yantarrnga, a 37-year-old Aboriginal man with significant cardiac history (prior mitral valve replacement in 1996), presented with chest and right-sided pain, fever, and was assessed by ambulance officers on 29 …

emergency medicineparamedicinediagnosticcommunicationwarfarin
SA2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes including neck compression due to hanging (Ward, Ryan, Cooper) a…

This inquest into four deaths on the Anangu Pitjantjatjara Lands involved multiple causes including hanging (three cases) and exposure with complications. Kunmanara Ward died by hanging while intoxicated with petrol; Kun…

psychiatryemergency medicinecommunicationsystempetrol
SAcommunity2005-03-14

Coroner's Finding: Cooper Kunmanara

Male·Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposure in cont…

Four separate inquests into the deaths of Kunmanara Ward (19), Kunmanara Ken (35), Kunmanara Ryan (25), and Kunmanara Cooper (27) on the Anangu Pitjantjatjara Lands between May 2003 and March 2004. Three deaths were by h…

psychiatrygeneral practicedelaycommunicationpetrol
SAcommunity2005-03-14

Coroner's Finding: Ryan Kunmanara

Unknown·Multiple; Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposu…

Four Aboriginal individuals died on Anangu Pitjantjatjara Lands between May 2003 and March 2004. Ward (19) and Ryan (25) died by hanging with evidence of petrol intoxication. Ken (35) died from exposure after wandering a…

psychiatryemergency medicinedelaysystempetrol
SAcommunity2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes: hanging (three cases); exposure in context of organic brain dam…

Four Anangu (Aboriginal) young men died between May 2003 and March 2004 on the Anangu Pitjantjatjara Lands in South Australia. Three deaths were by hanging (ages 19, 25, 27); one by exposure (age 35). Deaths were linked …

psychiatryemergency medicinesystemdelaypetrol
SAcommunity2005-03-14

Coroner's Finding: KEN Kunmanara

19y · Male·neck compression due to hanging

Kunmanara Ward, aged 19 years, died on 22 May 2003 by hanging from playground equipment at Indulkana Community while intoxicated by petrol sniffing. He had been sniffing petrol since early adolescence and was angry and u…

petrol
WAcommunity2005-03-11

Inquest into the Deaths of Judith Lesley Ward and Lorraine Melia

Female·Judith Lesley Ward died as a result of Thermal Injury; Lorraine Melia died as a …

Two deaths resulted from a bushfire started on 27 December 2003 near Tenterden, Western Australia, caused by conductor clashing on a Western Power 22kv overhead line. The fire was ignited when the live red phase conducto…

systemdelay
WAhospital2005-03-03

Inquest into the Death of Giovanni Bertoncini

72y · Male·acute gangrene of colon with probable perforation along with bowel obstruction a…

Giovanni Bertoncini, a 72-year-old man with diabetes and cardiac disease, presented to Sir Charles Gairdner Hospital on Christmas Day 2002 with acute abdominal pain and vomiting. Over two days, his condition deteriorated…

emergency medicinegeneral medicinediagnosticdelayparacetamol
VIChome2005-02-11

AYRE Gordon

Male·Drowning

Gordon Maxwell Ayre, a toddler, drowned in an unfenced farm dam while visiting a family property in rural Victoria. He was found floating by his father, who immediately commenced CPR. Paramedics continued resuscitation, …

QLD2005-02-09

Landue, Shone; Reid, Gary; Doolan, Stanley

Male·smoke inhalation (Landue and Doolan); smoke inhalation and effects of burning (R…

Three residents died in a boarding house fire at Sandgate, Queensland in August 2002. The fire started beneath the elevated timber building where a large quantity of flammable materials (mattresses, paint tins, timber, t…

systemcommunication
SAhospital2005-01-18

Coroner's Finding: SQUIRES Dorothy Alberta

90y · Female·incompatible blood transfusion resulting in haemolysis and multi-organ failure c…

A 90-year-old woman with acute myocardial infarction and cardiogenic shock died after receiving an incompatible blood transfusion (A- instead of O+), which caused haemolysis and multi-organ failure. The registered nurse …

cardiologyintensive careproceduralcommunication
WAcommunity2005-01-11

Inquest into the Death of Tony Martin

25y · Male·Unlawful Homicide by person or persons unknown

Tony Martin was a 25-year-old Aboriginal man placed on probation in September 1994 following minor criminal charges. He was mandated to reside at Gilroyd Pastoral Station under the supervision of William Ryan. On 24 Dece…

systemdelay
QLDhome2005

Shaw, Lillian Margaret

67y · Female·perforated gastric ulcer; morphine toxicity also made a significant contribution

Mrs Lillian Shaw, a 67-year-old obese woman with a history of NSAID use, presented with vomiting and abdominal pain over 36 hours. A GP visited three times without performing adequate physical examination, failed to insp…

general practicegastroenterologydiagnosticmedicationtramadol
NThome2004-12-24

Inquest into the death of Marie Kirwin

39y · Female·drowning associated with drug toxicity

Marie Kirwin, aged 39, died by drowning in her home swimming pool in the early hours of 15 September 2002. Toxicological analysis revealed a toxic level of temazepam (1.2 mg/L) and therapeutic level of promethazine in he…

general practicetoxicologytemazepam
NT2004-12-22

Inquest into the death of Isobel Von Jordan

20y · Female·Drowning during the course of a crocodile attack

Isobel Von Jordan, a 20-year-old German university student, drowned during a saltwater crocodile attack at Sandy Billabong in Kakadu National Park on 22 October 2002. Tour guide Glenn Robless led the swimming group to an…

proceduralsystem
QLD2004-12-20

Cif Fiechtner Rj 20041220

Male·Burns received in a gas explosion on a drilling rig

This was an industrial fatality on a gas drilling rig in the Surat Basin on 7 April 2003. Rodney Fiechtner, the rig manager, died from thermal burns covering 95% of his body after an uncontrolled natural gas release and …

proceduralsystem
SAhospital2004-12-14

Coroner's Finding: O'NEILL Louise Kay

31y · Female·mixed drug toxicity (propoxyphene, fluvoxamine, and alprazolam)

A 31-year-old woman with extensive history of deliberate self-harm and prescription drug abuse died from mixed drug toxicity (propoxyphene, fluvoxamine, and alprazolam). She presented to the emergency department with a r…

emergency medicinetoxicologydiagnosticcommunicationpropoxyphene
NTcommunity2004-12-14

Inquest into the death of Nikita Anderson

0y · Female·bronchopneumonia caused by hypoxic brain damage caused or contributed to by meni…

A 9-month-old Aboriginal girl died from bronchopneumonia caused by hypoxic brain damage following cardiorespiratory arrest due to meningitis and seizures. During resuscitation at a rural GP clinic, a CO₂ cylinder was ina…

general practicepaediatricsproceduralsystemadrenaline
WA2004-12-14

Inquest into the Death of Damien George Garlett

18y · Male·Ligature compression of the neck (hanging)

Damien George Garlett, an 18-year-old Aboriginal remand prisoner at Hakea Prison, died by ligature compression of the neck (hanging) on 4 April 2003. He had a history of self-harm, drug-induced psychosis, violent offence…

psychiatrypsychologydiagnosticcommunication
SAhome2004-11-18

Coroner's Finding: CUNNINGHAM Tracey-Lee

26y · Female·morphine toxicity complicated terminally by bronchopneumonia

A 26-year-old woman with chronic migraines and depression died from morphine toxicity complicated by aspiration pneumonia. She had a documented history of drug-seeking behaviour, forged prescriptions, and doctor-shopping…

general practiceneurologymedicationdiagnosticmorphine

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