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SAhome2002-11-06

Coroner's Finding: JERICHO Patricia Susanne

43y · Female·neck compression due to hanging

A 43-year-old woman with longstanding depression and previous suicidal ideation presented to Emergency Department twice within 14 days and was referred to psychiatric services. She had persistently refused antidepressant…

general practicepsychiatrycommunicationsystemaurorix
WAhospital2002-10-04

Inquest into the Death of Eric Clarence Moody

67y · Male·Aspiration of vomit associated with alcohol intoxication in a man with ischaemic…

Eric Clarence Moody, a 67-year-old man with diabetes, chronic alcoholism, and ischaemic heart disease, died on 6 December 1999 after aspirating vomit while heavily intoxicated with methylated spirits. He presented to Nor…

emergency medicinegeneral practicediagnosticcommunicationmethylated spirits
SAhospital2002-09-18

Coroner's Finding: McPHAIL Matthew Anthony

0y · Male·Hypoxic Ischaemic Encephalopathy (no legal death of person found; coroner declin…

A full-term infant, Matthew Anthony McPhail, was delivered at 9.55 pm on 9 July 2000 at Naracoorte Health Service with no signs of life (Apgar 0). CTG monitoring during labour showed concerning fetal bradycardia episodes…

obstetricsgeneral practicedelayoxytocin
SAhome2002-09-06

Coroner's Finding: HUNT Kunmanara

25y · Female·inhalation of petrol (hydrocarbon inhalation)

This is a complex coroner's inquest into three Aboriginal deaths from petrol inhalation on the Anangu Pitjantjatjara Lands. Kunmanara Hunt, age 25, died on 27 January 2001 after inhaling petrol fumes while lying face-dow…

toxicologyforensic medicinesystemdelaypetrol
SAhome2002-09-06

Coroner's Finding: KEN Kunmanara (2)

27y · Male·hydrocarbon inhalation

This inquest involved three deaths from petrol inhalation (1999-2001) on the Anangu Pitjantjatjara Lands. All three deceased were chronic sniffers (10+ years) who died from respiratory depression/asphyxia with distinctiv…

forensic medicinetoxicologysystemdelaypetrol
SAhome2002-09-06

Coroner's Finding: THOMPSON Kunmanara

29y · Male·inhalation of petrol (hydrocarbon inhalation) causing respiratory depression wit…

Three Aboriginal men aged 25-29 years died from petrol inhalation in identical circumstances over 1999-2001, each found face-down in bed with a shaped petrol can sealed to their face. All were chronic sniffers (>10 years…

toxicologyforensic medicinesystemdelaypetrol
VIChome2002-08-30

CARRIGG Yvonne

Female·Dothiepin toxicity

Yvonne Carrigg, a woman with recurrent post-natal depression, died from dothiepin overdose three days after psychiatric discharge. Critical clinical failures included: prescribing dothiepin (a cardiotoxic tricyclic antid…

psychiatrygeneral practicediagnosticmedicationdosulepin
VIChome2002-08-30

SMEETON Debra

34y · Female·Dothiepin toxicity in a setting of post-natal depression

Debra Smeeton, 34, died on 12 November 1999 from dothiepin toxicity following intentional overdose at home, eight days after giving birth. She had severe post-natal depression after her first child in 1996, requiring hos…

psychiatryobstetricscommunicationmedicationdosulepin
WAcommunity2002-07-23

Inquest into the Death of Daren Cheng Lim Tan

23y · Male·Thermal injury in association with electrocution

Daren Cheng Lim Tan, a 23-year-old graduate electrical engineer in Western Power's training program, died on 19 January 2000 from thermal injury and electrocution at the Coolgardie substation in Western Australia. While …

systemcommunication
WAcommunity2002-07-19

Inquest into the Death of Elizabeth Ann Studd

33y · Female·Immersion (drowning) by suicide

Elizabeth Ann Studd, a 33-year-old woman with longstanding borderline personality disorder, died by drowning in the Swan River on 28 August 1999. She had a severely traumatic childhood characterised by emotional neglect,…

psychiatrygeneral practicealprazolam
SAhome2002-07-11

Coroner's Finding: TAYLOR Yutta

47y · Female·serotonin syndrome due to combined toxicity of moclobemide and paroxetine

A 47-year-old woman with a long history of prescription drug abuse died from serotonin syndrome caused by combined toxicity of moclobemide (MAOI) and paroxetine (SSRI). She had experienced multiple previous overdoses and…

general practicepsychiatrydiagnosticmedicationmoclobemide
WAhome2002-07-05

Inquest into the Death of Bradley William Rapley

22y · Male·Hypoxic Ischaemic Encephalopathy due to suffocation

Bradley William Rapley, aged 22, died from hypoxic ischaemic encephalopathy on 2 September 1999 at Fremantle Hospital after a suicide attempt by suffocation in a Casuarina Prison cell on 25 August 1999. Rapley was a pris…

psychiatrygeneral practicesystemcommunicationdosulepin
SA2002-07-01

Coroner's Finding: THORPE Danny

48y · Male·Cause of death has not been determined; likely drowning, hypothermia, or trauma …

Danny Thorpe, an experienced abalone sheller, disappeared after his fishing boat capsized on 20 November 2000 near Ceduna, South Australia. The vessel overturned in rough weather conditions while the crew was returning f…

occupational and environmental healthforensic medicineprocedural
SAcommunity2002-06-19

Coroner's Finding: HEATLEY Alan Forsyth

17y · Male·cranial and facial trauma

A 17-year-old male with acute schizophrenia died from cranial and facial trauma after running off a 15.6-metre cliff during a psychotic episode. Hours before, he had been seen by a trainee psychologist who failed to reco…

psychologypsychiatrydiagnosticcommunication
VICcommunity2002-06-07

COUPER Gregory

43y · Male·Hypoxic/ischaemic encephalopathy resulting from asystolic cardiac arrest due to …

Gregory David Couper, 43, with chronic schizophrenia, experienced a psychiatric crisis at a supported residential care facility on 2 December 1998 and died the next day from restraint asphyxia. Police responded to calls …

psychiatrypathologyproceduralcommunication
WAcommunity2002-06

Inquest into the Death of David Stanley William Poole

40y · Male·Complications following fracture of the pelvis

David Stanley William Poole, a 40-year-old crane operator, fell from a mobile crane carrier approximately 1.6 metres to the ground while attempting to correct the positioning of packing timbers on the crane deck on 5 Apr…

emergency medicineorthopaedic surgerysystemdelaymorphine
SAcommunity2002-05-23

Coroner's Finding: DANN Kathleen Felicity

38y · Female·mixed drug toxicity (lethal level of dothiepin, potentially lethal level of morp…

A 38-year-old woman with long-standing heroin and benzodiazepine dependence died from mixed drug toxicity following injection of heroin. Her GP had prescribed multiple benzodiazepines (diazepam, oxazepam, temazepam) and …

general practiceaddiction medicinemedicationdiagnosticheroin
SAhome2002-05-23

Coroner's Finding: DAVIES Nicole Memory Faye

17y · Female·mixed drug toxicity

Nicole Davies, 17, died from mixed drug toxicity after rapid methadone dose escalation during early maintenance therapy. She presented with clear signs of intoxication (drowsiness, slurred speech, incoherence) yet receiv…

general practiceaddiction medicinediagnosticmedicationmethadone
SAcommunity2002-05-23

Coroner's Finding: DAVIES Nicole Memory Faye

17y · Female·mixed drug toxicity

Nicole Memory Faye Davies, age 17, died on 4 April 2000 from mixed drug toxicity. She enrolled in methadone maintenance with GP Dr T. on 27 March after moving from Melbourne. Dr T. rapidly escalated her dose from 35mg to…

general practiceaddiction medicinediagnosticmedicationmethadone
SAhome2002-05-22

Coroner's Finding: GREGG Robert

13y · Male·Electrocution

Robert Gregg, aged 13, died from electrocution in his family's underground dugout home in Coober Pedy after touching a defective floodlight connected via extension cords to an unearthed socket outlet lacking a residual c…

occupational and environmental healthpathologysystemdelay

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