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SAhospital2003-03-28

Coroner's Finding: BUTLER Irene

72y · Female·haemorrhage from penetrating duodenal ulcer

A 72-year-old woman collapsed at home and was admitted with black bowel motions (melaena) suggestive of gastrointestinal bleeding. This crucial history was documented by the ED doctor but not properly acted upon by the a…

emergency medicinegeneral medicinediagnosticcommunicationaspirin
SAmental health2003-03-28

Coroner's Finding: GAVA Mario

80y · Male·bilateral pulmonary thromboembolism

An 80-year-old man with dementia was detained under the Mental Health Act at Howard House (Hillcrest Hospital) for confusion, aggression, and behavioural disturbance. He died three days after admission from bilateral pul…

psychiatrygeriatric medicine
NT2003-03-28

Inquest into the death of Rita Dandy

38y · Female·Multiple injuries sustained in a motor vehicle accident in which the deceased wa…

Rita Dandy, a 38-year-old Aboriginal woman with chronic alcohol use disorder, died from multiple injuries after being struck by a motor vehicle while lying on the Stuart Highway near Darwin. She had been released from pr…

forensic medicineemergency medicinesystemdelayalcohol
SA2003-03-28

Coroner's Finding: ROGERS Justin Malcolm

27y · Male·propoxyphene toxicity

A 27-year-old man with schizophrenia died of propoxyphene toxicity while in police custody. He ingested a fatal dose of Doloxene capsules prescribed by Dr R. on 27 June 2000. The doctor prescribed 100 capsules to a patie…

general practicepsychiatrydiagnosticmedicationpropoxyphene
NT2003-03-21

Inquest into the death of Robert John Baxter

26y · Male·Multiple injuries sustained in aircraft accident - Cessna 210 stall and loss of …

Robert John Baxter, aged 26, died in a Cessna 210 aircraft crash on 4 February 2001 near Gapuwiyak airstrip, Arnhem Land. The pilot took control of an unfamiliar aircraft without conducting a pre-flight inspection and at…

aviation medicineproceduralsystem
SA2003-03-20

Coroner's Finding: VARCOE Alexander Wayne Keith

24y · Male·hanging

Alexander Varcoe, a 24-year-old Aboriginal man, died by hanging in Yatala Labour Prison while on remand awaiting trial for serious charges. He had a complex history including prior self-harm in 1995-96, alleged prison ra…

psychiatrygeneral practicesystemcommunication
VIChospital2003-03-18

HOGGINS Cheryl

48y · Female·Cardiorespiratory arrest due to cardiac tamponade as a result of perforation of …

Cheryl Hoggins, aged 48, died on 1 July 2000 from cardiac tamponade following perforation of the right atrium during central venous catheter exchange in ICU. She was recovering from emergency liver transplantation compli…

intensive caregeneral medicineproceduraldiagnosticnoradrenaline
SAhospital2003-03-17

Coroner's Finding: DeIONNO Orazio

40y · Male·ischaemic heart disease due to coronary atherosclerosis

A 40-year-old man presented to an Emergency Department with chest pain lasting approximately a week and a half, presenting with symptoms including arm pain and associated cough. He was triaged as Category 3 (non-urgent) …

emergency medicinecardiologydiagnostictriage
SAhospital2003-03-12

Coroner's Finding: STOLL Ruth Sophie

71y · Female·massive acute haemolysis leading to severe anaemia and multi-system failure as a…

Ruth Stoll, 71, died from massive acute haemolysis and multi-system failure after receiving incompatible blood transfusions during aortic aneurysm repair. Pre-operative blood samples from Stoll and another patient (Koven…

cardiothoracic surgeryanaesthesiadiagnosticprocedural
SAhospital2003-03-07

Coroner's Finding: GRAHAM Steven Barry

35y · Male·Cardiac arrest due to incessant ventricular fibrillation/ventricular tachycardia…

A 35-year-old previously healthy male sustained blunt chest trauma during an assault. He presented to ED with chest pain but was triaged as category 4. After collapse and retriage to category 3, he received an ECG at 1:0…

emergency medicinecardiologycommunicationsystemparacetamol/codeine
WA2003-03-07

Inquest into the Death of slater

28y · Male·Ligature compression of the neck (hanging)

Evan Charles Slater, 28, died by ligature compression of the neck (hanging) in Cell D7, Unit 10 of Hakea Prison on 12 March 2001. He was on remand facing assault and restraining order breach charges stemming from domesti…

psychiatrycorrectional healthcommunicationsystemanti-depressant medication
SAhospital2003-03-04

Coroner's Finding: VASSALLO Virginia

59y · Female·multiple cerebral infarction due to infective endocarditis

A 59-year-old woman with known mitral valve disease presented to the Emergency Department on 19 October 2000 with widespread body pain, severe back pain, and fever. She was undoubtedly suffering from staphylococcus aureu…

emergency medicinecardiologydiagnosticdelayparacetamol/codeine
NThome2003-02-26

Inquest into the death of Reba Lakuwanga

41y · Female·intra-abdominal haemorrhage caused by a ruptured spleen due to blunt force traum…

A 41-year-old Aboriginal woman died from a ruptured spleen caused by blunt force trauma from her intoxicated boyfriend after police failed to provide adequate care and protection. Officers Goldstein and Cook took her int…

proceduralcommunicationalcohol
VIChospital2003-02-01

AINALIDIS Taylor

0y · Male·Cardiorespiratory failure due to failure of anaesthetic rebreathe bag

Taylor Ainalidis, aged 3 weeks, died on 21 June 2000 at the Royal Children's Hospital following cardiorespiratory failure during resuscitation after surgery for Tetralogy of Fallot. The primary cause was failure of an an…

cardiothoracic surgeryanaesthesiasystemprocedural
SA2003-01-17

Coroner's Finding: ALLEN Craig Mark

29y · Male·Hanging

Craig Mark Allen, aged 29, died by hanging in cell 211 of Yatala Labour Prison on 16 October 2000, six days after admission for assault. Critical failures in prisoner management contributed to this preventable death. The…

correctional healthpsychiatrycommunicationsystemfluoxetine
SA2003-01-17

Coroner's Finding: HOWARD Brendon Alan and SNEATH Lois Creama

Multiple severe traumatic injuries sustained in motor vehicle accident

Two people died when a car lost control on a recently resealed rural road with loose aggregate still present. The female driver was traveling at approximately 90 km/h on a straight sealed section, but lost control about …

systemdelay
SAmental health2003-01-10

Coroner's Finding: MYNHART Johann George

77y · Male·bilateral pulmonary emboli complicating deep vein thrombosis (left calf)

A 77-year-old man with dementia died from bilateral pulmonary emboli complicating deep vein thrombosis of the left calf. He was hospitalised for dehydration and diabetes management, then returned to psychiatric care. On …

psychiatryemergency medicinecommunicationdelay
WAcommunity2002-12-20

Inquest into the Death of Lauren Jay Kitching

5y · Female·Head and neck injuries sustained in collision with utility vehicle while operati…

Lauren Jay Kitching, age 5, died on 5 July 2000 from head and neck injuries sustained in a go-kart collision at the Pauline Matika netball courts in Newman, Western Australia. She was participating in a holiday program f…

diagnosticsystem
SAhospital2002-11-29

Coroner's Finding: RICHARDSON Corey Shane

21y · Male·Cardiorespiratory arrest associated with butane abuse by inhalation

A 21-year-old detained psychiatric patient died from cardiorespiratory arrest following deliberate butane inhalation in a hospital wardrobe. He was admitted to an open mental health ward following acute psychosis, with d…

psychiatryforensic medicinesystemcommunicationbutane
VIC2002-11-15

Coroner's Finding: Peter Brubeck Wilson; John Francis Lowery

Male·Injuries sustained in gas explosion and fire following brittle fracture of heat …

On 25 September 1998, an explosion and fire at Esso's Longford Gas Plant 1 killed two workers and injured eight others. The direct cause was brittle fracture of a heat exchanger after cooling to -48°C due to loss of lean…

system

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