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WAhospital2020-11-20

Inquest into the Death of Trent Nathaniel ROBERTSON

44y · Male·head and neck injuries with terminal palliative care

Trent Robertson, 44, died from severe head and neck injuries sustained in a high-speed motorcycle crash on 27 May 2018 after evading a brief police traffic stop. Police observed him speeding at 92 km/h in a 60 km/h zone,…

trauma surgeryintensive care
NSWhospital2020-11-20

Inquest into the death of Melissa Stokes

49y · Female·Fatal Cardiac Arrhythmia

Melissa Stokes, 49, died from a fatal cardiac arrhythmia one day after successful abdominal hysterectomy and sling surgery. The coroner found the cause was not opioid-induced respiratory depression despite post-operative…

anaesthesiagynaecologycommunicationdelaytramadol
VICcommunity2020-11-19

Finding into death of Zachary Matthew Bryant

Unsurvivable traumatic injuries from blunt force impact with motor vehicle; pred…

On 20 January 2017, James Gargasoulas drove a stolen vehicle through Bourke Street Mall in Melbourne's CBD, striking 33 pedestrians and fatally injuring 6: Matthew Poh Chuan Si (33), Thalia Hakin (10), Yosuke Kanno (25),…

emergency medicinetrauma surgery
VICaged care2020-11-06

Finding into death of VA

73y · Female·Combined effects of congestive cardiac failure, coronary artery atherosclerosis …

VA, a 73-year-old woman with mental health conditions and cardiac disease, died from congestive cardiac failure, coronary atherosclerosis, and cardiomegaly while an inpatient in a psychiatric unit. She had recently been …

psychiatryintensive caremetaraminol
WAprison2020-11-04

Inquest into the Death of Damien PURNELL

47y · Male·organ failure following cardiorespiratory impairment in a man with arteriosclero…

Damien Matthew Purnell, a 47-year-old prisoner with a long history of polysubstance abuse and undiagnosed coronary artery disease, collapsed in his cell after smoking synthetic cannabinoids (Kronic). Despite immediate re…

emergency medicineintensive caresystemmethadone
SAhospital2020-11-03

Coroner's Finding: WHISKEY Louise Kitty

51y · Female·community acquired pneumonia

Louise Kitty Whiskey, a 51-year-old Aboriginal woman with chronic alcohol misuse, cirrhosis, and recurrent respiratory infections, died from community-acquired pneumonia at Royal Adelaide Hospital. She was admitted on 23…

intensive carepsychiatrysystemnoradrenaline
SAhospital2020-11-03

Coroner's Finding: MARSHALL Daryl Grant

61y · Male·hospital acquired pneumonia complicating aorto-femoral bypass surgery for periph…

A 61-year-old man with peripheral vascular disease, alcohol dependence, and heavy smoking history underwent aorto-femoral bypass surgery. Post-operatively he developed hospital-acquired pneumonia, delirium from alcohol w…

vascular surgeryintensive care
NSWcommunity2020-10-30

COOK Grant Findings

28y · Male·Hypoxic brain injury as a result of a respiratory arrest, after inadequate respi…

Grant Cook, aged 28, collapsed during a rugby league game after a tackle caused him to fall and hit his head. He suffered a grand mal seizure with snoring/obstructed breathing, leading to respiratory arrest, cardiac arre…

paramedicineintensive carecommunicationdiagnosticadrenaline
SAhospital2020-10-30

Coroner's Finding: VELT Hank Jakob

65y · Male·ischaemic and hypertensive heart disease with contributing acute cholecystitis (…

A 65-year-old man with hypertension presented with acute cholecystitis, underwent laparoscopic cholecystectomy, and initially recovered well. On post-operative day 7, he experienced chest pain radiating to his jaw. Two E…

general surgerycardiologydiagnosticcommunication
VICaged care2020-10-22

Finding into death of Phillip Harry Parker

61y · Male·Pneumonia

A 61-year-old man with significant medical complexity including acquired brain injury, bronchiectasis, pulmonary fibrosis, and dysphagia died from pneumonia 26 days after receiving another resident's slow-release opioid …

geriatric medicineemergency medicinemedicationsystemtapentadol sr
VIChospital2020-10-21

Finding into death of Baby ABA

0y · Female·Head injury

Baby ABA, born in Lebanon and arrived in Australia at 2 months old, died from head injury at 6.5 months of age on 10 June 2008. She had fallen from a couch on 7 June 2008 with no apparent serious injury. The following mo…

paediatricsintensive caredelay
SAhospital2020-10-12

Coroner's Finding: USHER Peter Michael

56y · Male·hypoxic ischaemic encephalopathy following insulin and benzodiazepine overdose

A 56-year-old man with depression, known to close friends but not formally disclosed to healthcare providers, deliberately ingested temazepam tablets accumulated over time and insulin stolen from his mother on 10-11 Nove…

anaesthesiapsychiatrytemazepam
SAhospital2020-10-12

Coroner's Finding: MANSVELDERS Henri Martinus Bernardus

79y · Male·Atherosclerotic right internal carotid artery occlusion with resultant ischaemia…

A 79-year-old man with significant cardiovascular disease history (prior MI, triple bypass, hypertension, hypercholesterolaemia) was admitted to psychiatric care under an Inpatient Treatment Order following suicidal idea…

psychiatryneurologymorphine
TASmental health2020-10-09

Coroner's Finding: Le Roy, Carole Ann

40y · Female·hypoxic encephalopathy due to asphyxia from hanging

A 40-year-old woman with extensive mental health history including OCD, complex trauma, severe depression, and recurrent suicidal ideation was admitted to an open psychiatric unit after expressing suicidal intent. Despit…

psychiatryintensive carediagnosticsystem
WAhospital2020-10-08

Inquest into the Death of Wayne Frederick LEESE

54y · Male·Complications including hepatic encephalopathy, pneumonia and multi-organ failur…

Wayne Frederick Leese, a 54-year-old prisoner, died from complications of hepatitis C and hepatocellular carcinoma including hepatic encephalopathy, pneumonia and multi-organ failure. He collapsed at Acacia Prison on 4 M…

hepatologyemergency medicinemethadone
TAScommunity2020-10-02

Coroner's Finding: Fish, Winston William

78y · Male·Multiple organ failure in the setting of neuropathy and coagulopathy caused by t…

Winston William Fish, aged 78, died from multiple organ failure following tiger snake envenomation while working on his rural property in Tasmania. He was bitten at least twice by a 1400mm tiger snake while working near …

emergency medicineintensive caretiger snake antivenom
VIChospital2020-09-29

Finding into death of Nicola Deleo

91y · Male·Complications following cardiac arrest in the setting of anaesthetic induction d…

A 91-year-old man with COPD, asthma, and previous cardiac arrest from suxamethonium died from complications following anaphylaxis to rocuronium during anaesthetic induction for emergency small bowel obstruction surgery. …

anaesthesiageneral surgerycommunicationsystemrocuronium
VIChospital2020-09-28

Finding into death of Graham William Summerfield

82y · Male·Complications of multiple injuries (palliated), sustained in a quad bike inciden…

An 82-year-old man died from complications of multiple injuries sustained in a quad bike incident. He had failed a VicRoads eyesight test two years earlier, losing his driver's licence, yet continued riding an unregister…

trauma surgeryintensive care
NSWhospital2020-09-25

Inquest into the death of Gregory MASTERS

52y · Male·Polypharmacy overdose of amitriptyline and doxylamine in the context of underlyi…

A 52-year-old man with chronic facial pain, depression, obesity, cardiovascular disease and obstructive sleep apnoea died following restraint in ICU. He had ingested a polypharmacy overdose of amitriptyline and doxylamin…

intensive carepsychiatryamitriptyline
WAhospital2020-09-23

Inquest into the Death of PT (Name Subject to Suppression Order)

5y · Female·aspiration of vomit with microscopic early pneumonia, in a child with a history …

A five-year-old girl with cerebral palsy and epilepsy resulting from non-accidental head injuries at two months old died from aspiration of vomit with early pneumonia. Critical lessons: bruising in non-ambulant infants i…

paediatricsgeneral practicediagnosticcommunicationtopiramate
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