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SAhospital2011-07-08

Coroner's Finding: BAIS Jamie Stuart

39y · Male·pneumococcal meningitis with severe cerebral oedema due to pneumococcal mastoidi…

Jamie Stuart Bais, a 39-year-old man with acute otitis media and sinusitis, was admitted to Flinders Medical Centre for what was thought to be a straightforward ENT infection. Over 15 days, he developed pneumococcal meni…

ENT surgeryinfectious diseasesdiagnosticcommunicationceftriaxone
SAhospital2011-06-22

Coroner's Finding: LAWRENCE Rebecca Mary

41y · Female·acute myocardial infarction

Rebecca Lawrence, a 41-year-old woman with no significant cardiac history, presented to the Royal Adelaide Hospital Emergency Department with chest pain on 4 November 2008. She had experienced a myocardial infarction (AM…

emergency medicinecardiologydiagnosticsystempantoprazole
SAcommunity2011-06-22

Coroner's Finding: TATCHELL Melissa Jay

28y · Female·bronchopneumonia complicating oxycodone toxicity

Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropri…

general practiceemergency medicinemedicationdiagnosticoxycodone
SAhospital2011-06-22

Coroner's Finding: TRENGROVE Ian

81y · Male·Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with co…

An 81-year-old man died from retropubic and retroperitoneal haemorrhage complicating pelvic fractures sustained in a fall at church. He was on warfarin for atrial fibrillation with an excessive INR of 4.6 at the time of …

emergency medicinegeneral medicinediagnosticcommunicationwarfarin
SA2011-06-08

Coroner's Finding: MORRIS Julia Hisae and JAST Raymond Glen

Unknown·Gunshot wound to the head (self-inflicted)

Two suicides occurred at a commercial firing range where individuals gained easy access to firearms. Julia Morris, 23, with documented borderline personality disorder and recent suicide attempt, was discharged from hospi…

psychiatryemergency medicinesystemcommunication
SAcommunity2011-05-12

Coroner's Finding: BAY-AN Cris Lupingay and PETERSONS Andrew Peter

Unknown·Multiple injuries sustained in motor vehicle collision

Two men died in a motor vehicle collision on 30 August 2008 following a high-speed police pursuit. Andrew Petersons (30) was driving a utility vehicle at excessive speed while impaired by alcohol (0.171% BAC) and diazepa…

alcohol
SAcommunity2011-05-12

Coroner's Finding: KILTIE Andrew

52y · Male·clozapine toxicity

Andrew Kiltie, 52-year-old Aboriginal man, died from clozapine toxicity on 26 December 2007. He had been on clozapine 400mg daily for 5 years with significant clinical benefit for aggressive behaviour and psychosis, enab…

psychiatrycardiologyclozapine
SAcommunity2011-05-06

Coroner's Finding: RAPHAEL Daniel Buddy

20y · Male·closed head injury

A 20-year-old man on a stationary scooter was struck from behind by a van while waiting to turn right at a traffic junction in poor visibility. The driver was monocular (one eye only) due to diabetic complications and fa…

ophthalmologyoccupational and environmental healthdiagnosticsystem
SAhome2011-04-07

Coroner's Finding: LEE Troy Thomas and MATTHEWS Scott Leslie

Troy Thomas Lee: acute neck compression due to hanging; Scott Leslie Matthews: m…

Two men died by suicide while on home detention bail awaiting trial. Troy Thomas Lee (38, hanging) and Scott Leslie Matthews (23, mixed drug toxicity from tramadol and alprazolam overdose) both died on their parents' pre…

general practicepsychiatrycommunicationdelaytramadol
SAhospital2011-04-07

Coroner's Finding: WATKINS Maureen

56y · Female·pulmonary thromboembolism due to left calf deep vein thrombosis

A 56-year-old woman with bipolar disorder died from pulmonary thromboembolism due to left calf deep vein thrombosis while detained under the Mental Health Act in hospital. She presented with seizures and underwent wrist …

general medicinepsychiatrydiagnosticcommunicationdiazepam
SAhospital2011-03-28

Coroner's Finding: ALLAN Vera

81y · Female·Severe cardiogenic shock complicating cardiac surgery

An 81-year-old woman died of severe cardiogenic shock following elective aortic valve replacement complicated by intraoperative haemodynamic instability and inadequate postoperative ICU management. The surgery involved e…

cardiothoracic surgeryanaesthesiamedicationcommunicationadrenaline
SAaged care2011-03-18

Coroner's Finding: HEATH Dawn Patricia

78y · Female·Severe burns sustained while smoking

A 78-year-old woman with dementia and significant manual dexterity deficits suffered fatal burns while smoking unsupervised in an aged care facility. Despite documented cognitive impairment and physical limitations preve…

systemcommunication
SA2011-03-18

Coroner's Finding: PRETTY Gregory William and WALKER Mostyn Edward Kerry

Male·Gregory William Pretty: multiple injuries; Mostyn Edward Kerry Walker: chest inj…

Two experienced motorcyclists collided head-on on a winding rural road in South Australia. The evidence indicates that Gregory Pretty's motorcycle crossed the centre line while negotiating a tight right-hand bend, collid…

forensic medicine
SAaged care2011-02-24

Coroner's Finding: SILLAND Asta

83y · Female·massive pulmonary thromboembolism due to left lower leg deep venous thrombosis

An 83-year-old woman with Alzheimer's dementia died at a residential care facility from massive pulmonary thromboembolism secondary to left lower leg deep venous thrombosis. She collapsed in a toilet cubicle and was foun…

geriatric medicineforensic medicine
SA2011-02-17

Coroner's Finding: RYAN Rhys Allan Gerard and HENSCHKE Jake Spencer

19y · Male·Rhys Allan Gerard Ryan: neck injury; Jake Spencer Henschke: neck and chest injur…

Two 19-year-old males died in a single-vehicle collision during a police pursuit on 25 March 2009 in Bridgewater, South Australia. The driver, Rhys Allan Gerard Ryan, had a blood alcohol concentration of 0.142% and canna…

systemcommunicationalcohol
SAcommunity2011-02-17

Coroner's Finding: WANGANEEN Derrick Terence Lee

24y · Male·upper cervical spinal crush injury due to motor vehicle accident

A 24-year-old male died from upper cervical spinal crush injury sustained in a high-speed motor vehicle crash while evading police. He had stolen a vehicle and drove recklessly at speeds of 160-220 km/h, significantly im…

forensic medicineneurologyalcohol
SAhospital2011-02-17

Coroner's Finding: WHYTE Mark Anthony

36y · Male·multiple injuries from motor vehicle collision

Mark Anthony Whyte, aged 36, died from multiple injuries sustained in a motorcycle collision after deliberately evading a random breath testing station while intoxicated (BAC 0.138%). He rode through a clearly visible RB…

alcohol
SA2011-02-09

Coroner's Finding: MADELEY Daniel Nicholas

18y · Male·respiratory failure secondary to closed chest trauma

Daniel Madeley, 18-year-old apprentice toolmaker, died from respiratory failure secondary to closed chest trauma after being entangled in a Soviet-era horizontal boring machine at his workplace in June 2004. The machine …

occupational and environmental healthsystemdelay
SAhospital2010-12-30

Coroner's Finding: D'AGOSTINO Antonia

59y · Female·sepsis due to faecal peritonitis due to perforation of sigmoid colon complicatin…

A 59-year-old woman died from sepsis due to faecal peritonitis following a bowel perforation during laparoscopic oophorectomy for a benign ovarian cyst. The perforation was repaired during the initial surgery, but the re…

gynaecologygeneral surgerydiagnosticdelaypethidine
SAhospital2010-12-13

Coroner's Finding: CLAYTON June Alethea

20y · Female·severe closed head injury with associated basal skull fractures

A 20-year-old woman died from severe closed head injury with basal skull fractures after being struck by a motor vehicle. The driver had a blood alcohol level of 0.07–0.17% at the time of collision. Eyewitness evidence a…

alcohol
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