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SA2003-09-25

Coroner's Finding: GOROSTIAGA Jessica

8y · Female·Closed head injury

An 8-year-old girl died from severe closed head injuries sustained when a bouncy castle (inflatable amusement structure) was lifted by a sudden whirlwind and collapsed. The child fell from the structure during its flight…

systemprocedural
SAhome2003-09-25

Coroner's Finding: SAMMUT-SMITH Jason Peter

16y · Male·fresh water drowning

Jason Sammut-Smith, a 16-year-old boy, died by fresh water drowning on 1 December 2001. The coroner found extensive evidence of physical abuse inflicted over months, including numerous bruises, abrasions, and injuries co…

forensic medicineemergency medicinesystemdelaydiazepam
SAhospital2003-09-18

Coroner's Finding: NEWTON Ronald Luke

7y · Male·Hypoxic-ischaemic encephalopathy due to reflex cardiac arrest triggered by blunt…

A 7-year-old boy died from hypoxic-ischaemic encephalopathy following a motor vehicle collision. He was seated on an unanchored booster seat and wearing an adult seatbelt. During the collision, the unsecured booster seat…

intensive careemergency medicinesystem
NTcommunity2003-09-05

Inquest into the death of Mark Corbett

48y · Male·Acute cardiac dysrhythmia of unknown cause; acute alcohol toxicity was a signifi…

Mark Corbett, a 48-year-old Aboriginal man, died from acute cardiac dysrhythmia while in police protective custody in Tennant Creek. He was apprehended twice for public intoxication on 10 July 2002. After leaving a sober…

emergency medicineanaesthesiacommunicationsystemalcohol
VICcommunity2003-08-19

Nguyen Cindy

2y · Female·irreversible cerebral anoxia and terminal inhalation bronchopneumonia resulting …

Cindy Nguyen, a 2-year-old girl, drowned at Footscray Swimming Centre on 10 November 2000 and died from irreversible cerebral anoxia and inhalation bronchopneumonia on 15 November 2000. The coroner found that the death r…

emergency medicineparamedicinesystemcommunication
WAhospital2003-08

Inquest into the Death of Richard Christopher Jankowski

39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…

Richard Christopher Jankowski, a 39-year-old man, died from hypoxic brain injury due to respiratory obstruction following emergency surgery for a dental abscess with cellulitis. After initial treatment with antibiotics, …

anaesthesiageneral surgeryproceduralcommunicationpropofol
NTcommunity2003-07-31

Inquest into the death of Annette Kunia

29y · Female·severed spinal cord between the first and second cervical vertebrae sustained wh…

29-year-old Aboriginal woman died when thrown from a vehicle during a police pursuit that lasted 3-4 minutes over 9.2 km on Alice Springs Airport Road. She suffered a severed spinal cord between C1-C2 vertebrae, consiste…

communicationsystemalcohol
VIC2003-07-31

Pettet & Guajardo

Unknown·Multiple injuries from motor vehicle collision due to loss of control of tanker …

On 26 January 2001, five people died when a petrol tanker driven by Ranjith Naranpanawa lost control on the South Gippsland Highway near Koo Wee Rup, Victoria. The tanker collided with two oncoming vehicles carrying the …

systemdelay
SA2003-07-24

Coroner's Finding: Whyalla Airlines

21y·Double engine failure and ditching. Primary causes: left engine crankshaft fract…

On 31 May 2000, Piper Navajo Chieftain VH-MZK ditched in Spencer Gulf after two engine failures, killing seven passengers and the pilot, with one person missing. The coroner found that the right engine was damaged by end…

aviation medicinesystemprocedural
NThospital2003-07-17

Inquest into the death of Lennie Pinawrut

67y · Male·acute renal failure with associated severe acidosis and hyperkalemia

A 67-year-old Aboriginal male with dementia was discharged from Royal Darwin Hospital on 4 November 2001 following cystoscopy and bladder neck incision for suspected obstruction. Critical communication failures meant the…

urologysurgerycommunicationdelaygentamicine
VIChospital2003-06-29

Finding into death of Mohammed Tartourssi

3y · Male·unascertained

Mohammed Tartoussi, aged 3 years 11 months, presented to Bell Street Family Medical Centre on 28 June 2003 with chest pain and mild upper respiratory symptoms. He was diagnosed with mild symptoms and given prednisolone. …

emergency medicinepaediatricsdiagnosticsystemsalbutamol
WA2003-06-06

Inquest into the Death of Phillip Reginald James Steel

43y · Male·Multiple injuries from fall

Phillip Reginald James Steel, aged 43, a machinery operator at Mt Keith Nickel Mine in Western Australia, died on 18 May 2001 when the D10 bulldozer he was operating fell over 100 metres into an open pit. He was working …

communicationsystem
SAcommunity2003-05-27

Coroner's Finding: GILLIES Wayne John

45y · Male·Bullet wound to the head - self-inflicted

A 45-year-old man with recurrent major depression died by self-inflicted gunshot wound in April 2000. His psychiatrists documented recent suicidal ideation and unstable mental state but determined he was not actively sui…

psychiatrygeneral practicecommunicationsystemvenlafaxine
VICcommunity2003-05-21

DACK Lindsay

43y · Male·Drowning

Lindsay Dack, aged 43, drowned on 26 December 2000 while crewing the yacht Spirit of Downunder in the Big Bay Race 2000 in Port Phillip Bay. He was thrown overboard during a sudden squall while working on the foredeck, w…

systemprocedural
SAhospital2003-05-08

Coroner's Finding: PRATT Shirley May

66y · Female·acute necrotising haemorrhagic mediastinitis

Mrs Pratt, aged 66, underwent elective gastroscopy at Kapunda Hospital. During the procedure she heaved, and blood was noted at the gastro-oesophageal junction. She was discharged the same afternoon with pain, only to re…

surgerygeneral surgerycommunicationsystemfentanyl
WA2003-04-29

Inquest into the Death of Mark Anselo Ugle

36y · Male·Acute on Chronic Myocardial Infarction

Mark Anselo Ugle, a 36-year-old Aboriginal man with a significant history of cardiac problems, seizures, and non-compliance with medication, died in East Perth Lockup on 9 December 2000 from acute on chronic myocardial i…

cardiologyemergency medicinecommunicationsystemmethamphetamine
SA2003-04-11

Coroner's Finding: BUCKLAND Paul William

23y · Male·exsanguination from amputation of right leg through hip joint

A 23-year-old professional scallop diver was fatally attacked by a great white shark off South Australia's coast. He died from exsanguination following amputation of his right leg. The coroner identified two critical fai…

procedural
SAhome2003-04-11

Coroner's Finding: YIALAS Dimitrios

23y · Male·neck compression due to hanging

A 23-year-old male with drug-induced psychosis died by hanging. He had a long history of substance abuse and behavioural problems, with multiple presentations to hospital and mental health services. In March 2001, he was…

psychiatrygeneral practicecommunicationsystemamitriptyline
WA2003-04-11

Inquest into the Deaths of Anthony Glynn Gard; Errol Frederick Glass

48y · Male·Multiple injuries with incineration (Gard); Incineration (Glass)

Two experienced aviation and power industry professionals died when their helicopter struck a spur power line during a routine fault-finding inspection. Anthony Gard (48), an experienced helicopter pilot, and Errol Glass…

aviation medicineproceduralcommunication
VIChome2003-04-07

DISKIN Eliana

5y · Female·disseminated candidiasis secondary to protein-energy malnutrition

Eliana Diskin, aged 5 months, died from disseminated candidiasis secondary to severe protein-energy malnutrition. After ceasing breastfeeding in late October 2000, her parents fed her exclusively with unfortified rice mi…

emergency medicinegeneral practicedelay

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