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WA2015-10-30

Inquest into the Death of Axel Josef CREMER

58y · Male·Methiocarb toxicity

A 58-year-old prisoner at Karnet Prison Farm died from intentional methiocarb pesticide ingestion (suicide). He had access to chemicals as part of his horticultural work role and was able to secrete methiocarb to his cel…

methiocarb
WAcommunity2015-10-23

Inquest into the Death of Paul Gregory CLIFTON

49y · Male·Complications arising from immersion (drowning)

Paul Clifton, an experienced 49-year-old skipper, died from complications of immersion (drowning) after his recreational fishing boat sank unexpectedly in open water near Lancelin, Western Australia on 2 June 2013. The b…

systemdelay
WAhospital2015-10-08

Inquest into the Death of Charles William MAPP

82y · Male·Pneumonia in an elderly man with advanced lung cancer (squamous cell carcinoma)

Charles William Mapp, 82, died of pneumonia secondary to advanced lung cancer at Sir Charles Gairdner Hospital. He had been an involuntary psychiatric patient at Graylands Hospital for nine years with chronic schizophren…

psychiatrypalliative care
WAcommunity2015-10-06

Inquest into the Death of Michael Joseph BOTTOMLEY

53y · Male·Multiple injuries from being run over by a waste removal truck

Michael Joseph Bottomley, a 53-year-old man with chronic alcohol dependency, depression, diabetes, and hepatitis C, was fatally struck by a waste removal truck in a Perth laneway at 11:55 pm on 3 May 2012. Earlier that e…

mirtazapine
WAhospital2015-09-18

Inquest into the Death of David Yehuda WEISER

70y · Male·gastrointestinal haemorrhage in a man with gastric ulcers

David Weiser, 70, presented to an emergency department with melaena and dizziness on 11 November 2012. An advanced trainee in emergency medicine, Dr H., examined him and found a haemoglobin of 92 g/L and elevated urea/cr…

emergency medicinegastroenterologydiagnosticcommunicationaspirin
WAcommunity2015-09-17

Inquest into the Death of MR TOBY

45y · Male·Head injury from motor vehicle rollover

Mr Toby, a 45-year-old Indigenous male with significant alcohol problems, died from head injuries sustained in a motor vehicle rollover on 25 August 2012. Police attempted a random breath test on an unsealed road north o…

systemcommunicationalcohol
WA2015-09-16

Inquest into the Death of Sean BRUCE

18y · Male·Multiple injuries sustained in motorcycle crash

Sean Bruce, 18, died from multiple injuries sustained in a motorcycle crash on 17 May 2012. He was riding a stolen motorcycle at excessive speed (90-134+ km/h in a 60 km/h zone) when he lost control at a roundabout. He h…

emergency medicinetrauma surgerymethamphetamine
WAhome2015-09-02

Inquest into the Death of Priscilla Fay STEPHENSON

28y · Female·combined drug toxicity (heroin and prescribed psychiatric medications)

Priscilla Stephenson, a 28-year-old Aboriginal woman with longstanding mental illness and polysubstance abuse, died from combined drug toxicity (heroin plus prescribed psychiatric medications) shortly after discharge fro…

psychiatryemergency medicineheroin
WAhospital2015-08-28

Inquest into the Death of Constantinas PAPAKOSTAS

66y · Male·carcinomatosis complicated by recurrent sepsis and multisystem failure in a man …

A 66-year-old man with renal cell carcinoma died in hospital from carcinomatosis with sepsis and multisystem failure. Critical clinical lesson: haematuria in 2005 was not adequately investigated with imaging despite recu…

urologyoncologydiagnosticdelay
WAcommunity2015-08-18

Inquest into the Deaths of Debra Alexandra TILL and Craig Allan RAABE

Ms Till: head injury with probable crush asphyxia; Mr Raabe: head injury

Two workers died when dongas (temporary accommodation buildings) were destroyed by Tropical Cyclone George at a remote mining camp 90km south of Port Hedland in March 2007. The buildings were designed and constructed to …

diagnosticsystem
WAhospital2015-08-12

Inquest into the Death of Helen Christine MacFARLAINE

52y · Female·intracerebral haemorrhage in a lady with underlying cerebrovascular disease and …

A 52-year-old woman underwent right carotid endarterectomy for high-grade stenosis. Post-operatively she developed escalating blood pressure readings (160–220 mmHg), headaches, nausea, agitation, and abnormal behaviour o…

neurosurgeryintensive carecommunicationsystemaspirin
WAhospital2015-08-06

Inquest into the Death of Francis Gerald ROBERTS

62y · Male·fatal cardiac arrhythmia secondary to end-stage ischaemic cardiomyopathy

A 62-year-old prisoner with severe ischaemic heart disease, diabetes, and cardiomyopathy died from a fatal cardiac arrhythmia in hospital. He had extensive cardiac history including pacemaker insertion, coronary stents, …

cardiologycardiothoracic surgeryfurosemide
WAhospital2015-07-29

Inquest into the Death of Tien Chung NGUYEN

55y · Male·ruptured dissection of the thoracic aorta

Tien Chung Nguyen, a 55-year-old male prisoner, died from rupture of a thoracic aortic dissection during emergency surgery at Royal Perth Hospital. He presented with chest pain and dyspnoea at Wooroloo Prison on 26 Novem…

emergency medicinecardiothoracic surgerydiagnostic
WAhome2015-07-22

Inquest into the Death of Armarnie-Bree ELLIOTT

2y · Female·pneumonia in a child with reported recent flu-like illness (multiple viral detec…

Armarnie-Bree Elliott, a 2-year-old with Angelman syndrome, died from pneumonia complicated by oxycodone toxicity. She developed flu-like symptoms in late April while at a women's refuge. On 2 May evening, appearing incr…

paediatricsgeneral practiceoxycodone
WAhospital2015-07-16

Inquest into the Death of James Anthony STANCZYK

31y · Male·ligature compression of the neck (hanging)

A 31-year-old man with depression, suicidal ideation, and recent HIV diagnosis presented to emergency department after suicide attempt (carbon monoxide inhalation and diazepam overdose). Despite psychiatrists identifying…

emergency medicinepsychiatrycommunicationsystemdiazepam
WAhospital2015-07-08

Inquest into the Death of Roy Charles GILBERT

49y · Male·Complications in Association with Advanced Gastric Malignancy

Roy Charles Gilbert, a 49-year-old prisoner serving an indefinite sentence, was diagnosed with advanced gastric adenocarcinoma in August 2013 after presenting with symptoms of constipation, weight loss, and vomiting. Gas…

oncologygastroenterology
WAhospital2015-07-02

Inquest into the Death of John MAJINSKI

55y · Male·Complications of fibrosing alveolitis

John Majinski, a 55-year-old prisoner with severe fibrosing alveolitis, pulmonary hypertension, diabetes, and recurrent infections, died from complications of his lung disease while incarcerated. He received intensive me…

respiratory medicinegeneral medicinemirtazapine
WA2015-06-22

Inquest into the Death of Shane John ROBINSON

29y · Male·Multiple drug toxicity

Shane John Robinson, a 29-year-old prisoner with complex medical conditions including Crohn's disease, pulmonary embolism, anaemia and schizoaffective disorder, died from multiple drug toxicity in prison. He had been pre…

gastroenterologycardiologysystemmethadone
WAhome2015-06-18

Inquest into the Death of MKP

15y · Female·Seizure Disorder in association with Long Standing Hypoxic Ischaemic Encephalopa…

MKP was a 15-year-old girl with severe cerebral palsy (GMFCS level 5) and long-standing hypoxic-ischaemic encephalopathy who died from a seizure disorder in her foster home on 26 December 2011. She had progressive respir…

neurologypaediatricsdelaydiazepam
WAhome2015-06-08

Inquest into the Death of Baby B

0y · Male·severe hypoxic ischaemic encephalopathy due to apparent perinatal asphyxia

Baby B suffered severe perinatal asphyxia during a planned home birth and died from hypoxic ischaemic encephalopathy. An obstetrician recommended hospital delivery based on the mother's previous unexplained neonatal emer…

obstetricsmidwiferycommunicationsystem
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