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WAhome2000-03-10

Inquest into the Death of Michael James Dwyer

30y · Male·acute combined heroin and alcohol toxicity; ingestion of alcohol and heroin

Michael James Dwyer, a 30-year-old man, died on 17 June 1999 at Royal Perth Hospital from acute combined heroin and alcohol toxicity. On 11 June, after returning from Melbourne, he consumed approximately one litre of gin…

emergency medicineintensive caredelayheroin
SAhospital2000-02-25

Coroner's Finding: STONEHOUSE Jarrod William (aka Scott)

23y · Male·aspiration of blood due to stab wound to trachea

23-year-old man with self-inflicted stab wound to neck presenting to emergency department while intoxicated and agitated. Ambulance noted 3cm laceration to midline trachea with minimal external bleeding. Registered nurse…

emergency medicinesurgerydiagnosticcommunicationalcohol
WA2000-02-11

Inquest into the Death of Sean Kevin Hayes

24y · Male·plastic bag asphyxiation

Sean Kevin Hayes, a 24-year-old male remand prisoner, died from plastic bag asphyxiation in his cell at Canning Vale Remand Centre in Western Australia on 20-21 August 1997. He had a history of psychiatric illness, previ…

psychiatrycorrectional healthsystemcommunicationstelazine
VIC2000-02-03

HINTERHOLZ Frederich

61y · Male·Head injuries from forklift tipover

A 61-year-old licensed forklift driver died when a Crown 35 SC TT 240 forklift tipped while the mast was extended, crushing his head. He was not wearing a seatbelt. Although the coroner found the employer had exemplary s…

proceduralsystem
WAmental health2000-01

Inquest into the Death of Steven Charles Indich

20y · Male·Ligature Compression of the Neck (Hanging)

Steven Charles Indich, a 20-year-old Aboriginal man with schizophrenia and a long history of psychotic symptoms, violent behaviour and substance abuse, died by suicide in Smith Ward at Graylands Hospital on 13 November 1…

psychiatryintensive caresystemhaloperidol
ACT1999-06-28

Inquest Into The Manner And Cause Of Death Of Mark Robert Watson

17y · Male·Cerebral ischaemia caused by hanging at Quamby Youth Detention Centre at approxi…

Mark Watson, a 17-year-old boy charged with assault, was detained at Quamby Youth Detention Centre. During his second remand in September 1996, after a failed hospital admission, he returned to the same unit where he had…

psychiatrypsychologysystemsupervision
VIChome1999-06-25

1997 DANDENONG RANGES FIRES

Fire exposure and carbon monoxide poisoning in a deliberately lit bushfire

The 1997 Dandenong Ranges fires killed three residents at Ferny Creek on January 21. Jennifer Lindroth (24), Graham Lindroth (26), and Genevieve Erin (50) died from fire exposure and carbon monoxide poisoning after shelt…

NThome1999-06

Inquest into the death of Clinton Leslie Kingsley

2y · Male·drowning

A 2-year-old Aboriginal boy drowned in an exposed septic tank at a remote community after plumbers removed concrete covers without installing replacements or notifying residents. The fibreglass lid's fastening screws had…

proceduralcommunication
VIChospital1999-03-29

JONES Eric

33y · Male·Postural asphyxia due to restraint (Posey Poncho vest)

A 33-year-old male admitted after drug overdose died from asphyxiation while restrained in a Posey Poncho vest. Successfully treated for overdose complications, he developed drug-induced delirium with agitation, promptin…

intensive careemergency medicineproceduralsystemmethadone
ACTcommunity1999-02-26

In The Matter Of The Death Of Warren Geoffrey Ianson

Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…

Warren I'Anson died from gunshot wounds to the mid-back on 17 November 1995 during a police response to a mental health crisis. He had schizophrenia, recently experienced grief from his wife and friend's deaths, and was …

psychiatryemergency medicinecommunicationsystemdiazepam
ACTcommunity1999

Inquest Into The Death Of Katie Bender

12y · Female·Head injury caused by high-velocity steel fragment missile, approximately 999 gr…

Katie Bender, aged 12, was struck fatally in the head by a 999-gram steel fragment while watching the controlled implosion of Royal Canberra Hospital on 13 July 1997. The fragment travelled 430 metres in 3.1 seconds at 1…

occupational and environmental healthdiagnosticprocedural
NTcommunity1998-09-02

Inquest into the death of Esky Muller

14y · Male·Loss of blood arising from incised wound to the left arm (cubital fossa)

A 14-year-old Aboriginal petrol sniffer brought to a remote outstation (Ilpurla) without pre-arrangement died from massive haemorrhage following a self-inflicted laceration to his arm. Clinical lessons: petrol sniffers i…

emergency medicineaddiction medicinediagnosticsystempetrol
ACThospital1998-07-16

Inquest Into The Death Of Nathan Thomas James Wrench

0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…

Nathan Wrench, 11 weeks old, presented to Queanbeyan Hospital on 14 October 1996 with persistent vomiting for 3 days. GP Dr R. diagnosed viral infection with possible reflux, admitted for observation, and managed conserv…

paediatric surgeryemergency medicinecommunicationdiagnostic
ACThome1998-03-06

Inquest Into The Circumstances Surrounding The Death Of Brian Joseph Duff

36y · Male·Toxic overdose of Clozapine (anti-psychotic drug), self-administered, with termi…

Brian Duff, a 36-year-old with severe chronic schizophrenia, died from Clozapine toxicity (pulmonary oedema and cardiac arrest) on 14-15 February 1997. He was subject to a Community Treatment Order and under case managem…

psychiatrycommunicationsystemclozapine
VIC1997-10-17

KEW Residential Services

Male·smoke inhalation and burns

On 8 April 1996, a fire at Kew Residential Services killed nine intellectually disabled residents (aged 31–61) from smoke inhalation and burns when a resident used a cigarette lighter to ignite bedding. The coronial inqu…

systemdelay
ACT1997

Inquest Into The Circumstances Surrounding The Death Of Shannon Robert Camden

21y · Male·Suffocation from hanging

Shannon Robert Camden, a 21-year-old with longstanding mental health difficulties and previous suicide attempts, died by hanging in cell A1 of the Belconnen Remand Centre on 15 April 1996 while on remand awaiting trial f…

psychiatrypsychologyproceduralsystem
TAShospital1996-10-01

Coroner's Finding: Muller Shar Marie

25y · Female·injuries sustained by jumping from the Tasman Bridge

A 25-year-old woman with longstanding borderline personality disorder, chronic suicidal ideation, and substance abuse died by jumping from the Tasman Bridge on 4 January 1996. She presented to the Emergency Department on…

psychiatryemergency medicinecommunicationsystemflunitrazepam
VIC1996-09-02

GALLAGHER GREEN Kevin

39y · Male·neck injuries from being crushed between a hydraulic ram and hydraulically opera…

Kevin Gallagher-Green, 39, died from neck injuries when crushed between hydraulic machinery at BHP Western Port Steel Works while attempting to adjust a tilt table height. The coroner identified multiple system failures:…

proceduralsystem
VIChospital1996-08-16

LONG June

69y · Female·Asthma

June Sylvia Long, aged 69, suffered an asthma attack at home on 28 June 1994 and was transported to Alfred Hospital. She deteriorated overnight in the hospital's Respiratory Ward despite initial improvement in Emergency …

respiratory medicineemergency medicinediagnosticcommunicationsalbutamol
NT1994-12-20

Inquest into the death of T. Okano, A. Kabe, T. Linklater and K. Pritchard (Cannonball Run)

Kabe 40, Okano 35, Linklater 22, Pritchard 31y · Male·Kabe and Okano: blunt head injury (head-to-head collision of occupants within ve…

On 24 May 1994, Ferrari F40 driver Akihiro Kabe entered a checkpoint lay-by at excessive speed (>100 kph, possibly 150 kph) following the 87.3 km mark where he mistakenly believed the checkpoint was located. The Ferrari …

emergency medicineforensic medicinedriver errorsystem error

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