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SAhome2014-01-31

Coroner's Finding: HADLEY Duke Zenon

2y · Male·Asphyxiation due to neck and/or chest compression

A 2-year-old boy died from asphyxiation due to chest and neck compression inflicted by his mother during an acute manic psychotic episode. The mother had been admitted to psychiatric care in December 2008 with psychosis …

psychiatryemergency medicinecommunicationsystemrisperidone
SAhome2014-01-31

Coroner's Finding: ROWAN Marjorie June

52y · Female·ischaemic and hypertensive heart disease

A 52-year-old woman with depression, diabetes, and hypertension died at home from ischaemic and hypertensive heart disease. She was prescribed dothiepin 225mg daily for depression management. Following gallbladder surger…

psychiatrygeneral practicedosulepin
SAaged care2013-11-29

Coroner's Finding: BETTS Lawrence

9y · Male·sigmoid volvulus

Lawrence Betts, a 9-year-old Aboriginal boy with Goldenhar syndrome and developmental disability including pica (ingesting foreign substances), died from sigmoid volvulus complicated by ingestion of soil, sand, and stone…

paediatricsgastroenterologysupervisionsystem
SAcommunity2013-10-02

Coroner's Finding: QUINN Paul James

31y · Male·gunshot wounds to liver, right lung and heart

Paul James Quinn, aged 31, died from gunshot wounds sustained during a police operation on 19 September 2010. Quinn was evading police on parole and was involved in armed robberies. During a pursuit in Forestville, Quinn…

methamphetamine
SAhospital2013-09-30

Coroner's Finding: GIANNINI Pasquale

68y · Male·infarction of the small and large bowel due to superior mesenteric artery thromb…

A 68-year-old man with extensive systemic vascular disease presented with 10 days of nonspecific abdominal pain. Initial presentations at local hospital and GP were attributed to possible gallstones or gastritis based on…

general practiceemergency medicinediagnosticdelayaugmentin duo
SAhospital2013-09-19

Coroner's Finding: HOCKING Robert Nicholas

67y · Male·aspiration pneumonia with contributing chronic schizophrenia

Robert Nicholas Hocking, a 67-year-old man with treatment-resistant chronic schizophrenia, died from aspiration pneumonia during his final hospitalization at Royal Adelaide Hospital. He was a long-term inpatient at Glens…

psychiatrygeneral medicineolanzapine
SA2013-09-19

Coroner's Finding: NICOLAI Adam Mark and HELLYER Justin Shane

28y · Male·Salt water drowning (Nicolai); exposure to the sea – probable drowning (Hellyer)

Two men aged 28 drowned after their fishing vessel sank in the Gulf of St Vincent on 28 September 2008 when struck by two large waves. The vessel was inherently unsafe due to an unbalanced centre of gravity from an added…

systemprocedural
SAmental health2013-09-19

Coroner's Finding: SZCZEPANIAK Eugeniusz

75y · Male·neck compression due to hanging

A 75-year-old man with chronic paranoid schizophrenia, detained under the Mental Health Act in a high-dependency psychiatric unit, died by hanging in his ensuite bathroom. He had been admitted after allegedly assaulting …

psychiatrygeriatric medicinedocumentationsystemrisperidone
SAaged care2013-09-05

Coroner's Finding: DICKER Ruth Ann

83y · Female·neck compression from a wheelchair restraint strap

Ruth Ann Dicker, an 83-year-old resident of an aged care facility with epilepsy, Parkinson's disease, and dementia, died from neck compression caused by a wheelchair lap belt restraint. After a significant history of fal…

geriatric medicineorthopaedic surgerysystem
SAhospital2013-09-04

Coroner's Finding: ARKADIANOS Dionisios

75y · Male·pneumonia complicating chronic renal and cardiac failure, vascular dementia and …

A 75-year-old man with chronic cardiac and renal failure, vascular dementia, and COPD died of pneumonia while detained under the Mental Health Act at Flinders Medical Centre. He was admitted with chest pain and remained …

cardiologypsychiatryenoxaparin
SAhospital2013-09-04

Coroner's Finding: BUGG Linda Edith

92y · Female·acute myocardial infarction

Linda Edith Bugg, aged 92, died of acute myocardial infarction at Royal Adelaide Hospital on 24 October 2009. She was admitted from Howard House with nausea, vomiting, and hypotension; tests indicated acute heart attack.…

cardiologypsychiatry
SAhospital2013-09-04

Coroner's Finding: THALBOURNE-MAITREYA Michael Anthony

55y · Male·toxic effects of quetiapine and clonazepam

A 55-year-old man with bipolar affective disorder died from toxic effects of quetiapine and clonazepam after intentional overdose. He was found unconscious at home and admitted to ICU at Royal Adelaide Hospital where he …

emergency medicineintensive carequetiapine
SAhome2013-09-03

Coroner's Finding: KROMWYK Shane Andrew

38y · Male·mixed drug toxicity and arrhythmogenic right ventricular dysplasia

Shane Andrew Kromwyk, aged 38, died at home on 14 March 2009 while on home detention bail. Post-mortem examination revealed mixed drug toxicity (methadone, diazepam, alprazolam) combined with pre-existing arrhythmogenic …

general practiceaddiction medicinediagnosticmedicationmethadone
SAhospital2013-09-03

Coroner's Finding: MUMFORD Michael John

41y · Male·multi-organ failure due to severe lactic acidosis due to metformin toxicity

A 41-year-old man with depression, anxiety, and substance abuse history deliberately ingested 390 metformin tablets on 24 December 2009 in a suicide attempt. He presented to the ED conscious and coherent, reporting the o…

intensive careemergency medicinemetformin
SAaged care2013-08-30

Coroner's Finding: CHAPLIN Doreen Hilda

82y · Female·fat embolism syndrome and bronchopneumonia following nail fixation of bilateral …

An 82-year-old woman with severe dementia and marked osteoporosis died from fat embolism syndrome and bronchopneumonia following surgical fixation of bilateral femoral fractures. The fractures occurred on 10 September 20…

orthopaedic surgerygeriatric medicineproceduralsystem
SAhospital2013-08-27

Coroner's Finding: BALNAVES Craig Henri

43y · Male·ischaemic small intestine due to incarceration of bowel in a mesenteric defect

Craig Henri Balnaves, a 43-year-old man with treatment-resistant schizophrenia detained at Glenside Hospital under mental health orders, died from ischaemic small intestine due to bowel incarceration in a congenital mese…

general surgerypsychiatryantacid
SAhospital2013-08-19

Coroner's Finding: HUNT William Edward

62y · Male·chronic congestive cardiac failure due to severe aortic valve stenosis and incom…

William Edward Hunt, aged 62, a life-sentenced prisoner, died from chronic congestive cardiac failure due to severe aortic valve stenosis and cardiomyopathy. His severe aortic stenosis was identified in 2003, but surgica…

cardiologycardiothoracic surgerydelaycommunicationfurosemide
SAhospital2013-08-19

Coroner's Finding: MOXON John William

69y · Male·Advanced motor neurone disease leading to terminal respiratory failure

A 69-year-old man died in custody from advanced motor neurone disease with terminal respiratory failure. He experienced progressive arm and leg weakness from March 2009, initially attributed to angina. Neurological refer…

neurologycorrectional healthdelayriluzole
SAhospital2013-08-19

Coroner's Finding: WEEKS Ronald Geoffrey

84y · Male·respiratory failure due to hospital-acquired pneumonia

Ronald Geoffrey Weeks, aged 84, died of respiratory failure due to hospital-acquired pneumonia following a hip fracture sustained in a fall at James Nash House psychiatric facility. He was serving an 8-year sentence for …

geriatric medicineorthopaedic surgerysystemdelay
SAhospital2013-08-15

Coroner's Finding: STOCK Anthony Douglas

64y · Male·hypoxic-ischaemic encephalopathy complicating cardiac arrest due to retroperiton…

A 64-year-old man died from hypovolaemic cardiac arrest caused by retroperitoneal bleeding from a pelvic fracture. The bleeding occurred six days post-injury while on high-dose enoxaparin (100mg twice daily) initiated un…

orthopaedic surgeryemergency medicinediagnosticcommunicationenoxaparin
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