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SAhospital2004-11-18

Coroner's Finding: PEDDEY Ross Dudley

63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…

A 63-year-old man died from pneumonia complicating anoxic brain injury following a post-operative haemorrhage from the inferior epigastric artery during ileostomy closure surgery. The critical failure was a 2.5-hour dela…

colorectal surgerygeneral surgerydiagnosticdelaywarfarin
VIChome2004-11-18

Armand Christian

56y · Male·Malignant Pleural Mesothelioma

Christian Armand, a self-employed carpenter and builder, contracted malignant pleural mesothelioma from occupational exposure to asbestos cement products during home renovation work in Victoria in the 1970s–1980s. An occ…

occupational and environmental healthpublic healthsystem
WAhome2004-11-03

Inquest into the Deaths of Jack Craig Anstey and Ashleigh Fiona Mungur

Immersion (Drowning)

Two children, Jack Craig Anstey (7) and Ashleigh Fiona Mungur (8), drowned on 3 October 2003 when the Jeep Cherokee in which they were passengers was washed from a low-level ford crossing of the Blackwood River on Jalbar…

systemdelayamphetamine
WAhome2004-10-28

Inquest into the Death of Kelly

33y · Female·Combined drug toxicity, with thioridazine as the principal component, in the con…

Lou Ann Kelly, aged 33, died on 3 April 2003 at Royal Perth Hospital ICU from combined drug toxicity, primarily thioridazine, after consuming large quantities of prescription medications with alcohol. She collapsed at he…

general practicepsychiatrysystemthioridazine
QLDcommunity2004-10-28

Cif Shoobridge Gr 20041028

25y · Male·Cardiorespiratory failure due to unpredictable additive effect of combination of…

George Shoobridge, a 25-year-old man with a long history of polydrug addiction, died from cardiorespiratory failure caused by the unpredictable additive effect of multiple drugs in combination (diazepam, morphine, codein…

general practiceaddiction medicinecommunicationsystemdiazepam
WA2004-10-14

Inquest into the Death of Charles Raymond Gamble

30y · Male·Ligature compression of the neck (hanging)

Charles Raymond Gamble died on 6 May 2003 by ligature compression of the neck while in lawful custody in an AIMS transport vehicle travelling from Perth Watch-house to Perth Central Law Courts. He had recently confessed …

communicationsystemmirtazapine
QLD2004-10-14

Cif Toohey Ap Hil At 20041020

Male·Severe head injuries due to motor vehicle accident

Two experienced bushmen, Alan Paul Toohey and Andrew Tasman Hill, died on 24 April 2003 when a police vehicle pursuing their unroadworthy utility truck crashed over an embankment on a remote unsealed road in Far North Qu…

system
NTPodcast2004-10-01

Inquest into the death of Jade Lange-Loades, Rory Lange-Loades and Nathaniel Rose

8y · Male·Drowning as the result of a motor vehicle accident

Three children drowned following a motor vehicle accident on the Stuart Highway after a grouser plate fell from an inadequately restrained load on a road train, puncturing their vehicle's tyre and causing loss of control…

proceduralsystem
SA2004-10-01

Coroner's Finding: MAGEE Liam

19y · Male·traumatic rupture of the thoracic aorta with bilateral haemothoraces

A 19-year-old experienced motorcycle racer died from traumatic aortic rupture and bilateral haemothoraces after colliding with a concrete wall at 100 km/h at a racing circuit. He lost control at approximately 205 km/h an…

systemdelay
QLDmental health2004-09-30

Cif Lee Ja 20040930

23y · Male·compression of the neck, secondary to coronary arteriosclerosis

Julian Arasina Lee, a 23-year-old man, died on 1 February 2003 during a restraint incident in the Mental Health Unit at Cairns Base Hospital. Admitted voluntarily after exhibiting marked behavioral changes, he became inc…

psychiatryemergency medicineproceduralcommunicationdroperidol
SAcommunity2004-09-10

Coroner's Finding: CORNISH Peter Henry

43y · Male·aspiration of vegetable matter with occlusion of the upper airway

Peter Cornish, a 43-year-old man with a 17-year history of bipolar disorder, died on 25 September 2001 from aspiration of vegetable matter while experiencing a severe manic episode. In the two weeks before his death, mul…

psychiatryemergency medicinediagnosticsystemcannabis
SAcommunity2004-09-03

Coroner's Finding: EUSTICE Dean Stanley

73y · Male·ischaemic heart disease due to coronary atherosclerosis

A 73-year-old man found a purse at a shopping centre and attempted to leave his details with the information desk rather than hand it in directly. A security officer, believing him suspicious, confronted, accused him of …

cardiologyemergency medicineproceduralcommunication
WAmental health2004-09

Inquest into the Death of Peter Daniel Mahoney

55y · Male·Immersion (Drowning) arising by way of suicide

Peter Daniel Mahoney, a 55-year-old man with treatment-resistant bipolar affective disorder, died by drowning on 13 June 2003 after absconding from Joondalup Health Campus where he was detained as an involuntary patient …

psychiatrypsychiatrycommunicationsystemtemazepam
SA2004-08-27

Coroner's Finding: CUNLIFFE David

35y · Male·Cerebral lacerations associated with comminuted fractures of cranial vault and b…

David Cunliffe, aged 35, died from severe cerebral lacerations and comminuted skull fractures sustained when ejected from a vehicle during a rollover accident on Jungfer Road, Lobethal, South Australia on 27 February 200…

WAhospital2004-08-16

Inquest into the Death of Gregory Andrew Furniss

25y · Male·cerebral craniopharyngioma

Gregory Andrew Furniss, a 25-year-old male with a history of asthma and congenital cataracts, presented to Swan District Hospital on 11 August 2002 with a persistent headache. He was seen by Dr H. (registrar) who diagnos…

emergency medicinegeneral practicediagnosticdelayterbutaline
SA2004-08-06

Coroner's Finding: FREDERICKS Jeffrey Ronald

41y · Male·haemorrhage due to incised wounds to left and right cubital fossae

Jeffrey Ronald Fredericks, aged 41, died in Adelaide Remand Centre custody from haemorrhage due to self-inflicted incised wounds to both cubital fossae. Critical clinical lessons: screening tools identified significant s…

general practiceemergency medicinediagnosticcommunicationdosulepin
SA2004-08-06

Coroner's Finding: TURNER Troy Phillip

36y · Male·hanging

Troy Phillip Turner, aged 36, died by hanging in his prison cell on 2 September 2001 while on remand for serious domestic violence-related offences. The coroner identified several preventable failures: (1) Duty Superviso…

psychiatryemergency medicineproceduralsystemfluvoxamine
NThome2004-08-05

Inquest into the death of Stephen Power

35y · Male·left lower lobe pneumonia

Stephen John Power died of left lower lobe pneumonia on 5 September 2003 after two failed emergency calls requesting ambulance assistance. On Thursday 4 September, dispatcher Coralie Holland failed to send an ambulance d…

emergency medicineparamedicinecommunicationsystemflucloxacillin
SAhospital2004-07-20

Coroner's Finding: QUINN Latoya Shelley

12y · Female·raised intracranial pressure due to ventriculo-peritoneal shunt blockage

A 12-year-old girl with congenital hydrocephalus and a ventriculo-peritoneal shunt presented to the ED with severe unrelieved headache after head trauma. An inexperienced junior doctor (6 weeks in role, minimal neurosurg…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
SAcommunity2004-07-16

Coroner's Finding: DINSDALE Cheree Ann and KLINGNER Peter James

20y · Unknown·Traumatic brain damage complicating gunshot wound to the head

Two young adults aged 20 died from gunshot wounds to the head on 29-30 May 2001 in what appears to be a murder-suicide involving Peter Klingner and his girlfriend Cheree Dinsdale. Klingner had paranoid schizophrenia with…

psychiatryemergency medicinediagnosticcommunicationolanzapine

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