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WAhome2015-06-08

Inquest into the Death of Baby C

0y · Male·Group B Streptococcal infection and meconium aspiration with early bronchopneumo…

A newborn died of Group B Streptococcal (GBS) infection and meconium aspiration bronchopneumonia less than three hours after planned home birth. The infant was born to a woman with prior traumatic hospital birth who had …

midwiferyobstetricsdiagnosticdelay
WAhome2015-06-08

Inquest into the Death of Baby P

0y · Male·intrapartum hypoxia due to placental abruption

A second twin boy was born at home despite medical advice that twin pregnancies require hospital care. The mother, who strongly preferred home birth, disengaged from hospital when her preferences for birth management (va…

obstetricsmidwiferycommunicationdelay
WA2015-06-05

Inquest into the Death of Luke Ross BEVEN

18y · Male·Multiple injuries sustained in motor vehicle collision

An 18-year-old male died from multiple injuries sustained when the vehicle he was a passenger in collided with trees during a high-speed police pursuit on 13 January 2012. The driver, affected by methylamphetamine and dr…

methamphetamine
WA2015-06-02

Inquest into the Death of Justin Aaron KING

36y · Male·Multiple injuries from motorcycle collision

Justin Aaron King, aged 36, died on 30 September 2011 when his Harley Davidson motorcycle collided with a vehicle at the intersection of Great Eastern Highway and Bullarra Road, Greenmount, Western Australia. He had perf…

alcohol
WA2015-05-26

Inquest into the Death of Samuel Eya LEOPOLODO

27y · Male·Unascertained - either multiple injuries or immersion (drowning) or combination …

Samuel Leopoldo, a 27-year-old Filipino seafarer, died after falling overboard from the container ship MSC Siena on 17 November 2011 while rigging a pilot ladder in rough seas near Rottnest Island, Western Australia. He …

systemcommunication
WA2015-04-17

Inquest into the Death of Danielle Kiesha LANE

8y · Female·heat stroke and dehydration

An 8-year-old girl from Tjirrkarli, a remote Aboriginal community in Western Australia, died from heat stroke and dehydration after becoming stranded in the desert. On 31 December 2011, she and an adult companion became …

WAcommunity2015-04-05

Inquest into the Death of Thomas Charles WILLIAMS

37y · Male·Immersion (drowning)

Thomas Charles Williams, 37, drowned in the Canning River on 7 August 2012 after fleeing from police. He was spotted by officers responding to a suspicious person report while in possession of illicit drugs and with an o…

pathologyforensic medicinemethamphetamine
WA2015-03-27

Inquest into the Death of Ramaiah MAHENTHIRAN

50y · Male·coronary atherosclerosis

A 50-year-old Tamil Sri Lankan man in immigration detention at Curtin IDC died from severe coronary atherosclerosis. He was assessed using a temporary "fast track" health screening process due to overcrowding at Christma…

emergency medicineoccupational and environmental healthglyceryl trinitrate
WA2015-03-17

Inquest into the Death of Thomas Francis LEVINGE

73y · Male·Unknown (possibly impact with water, drowning, injury, exhaustion, dehydration, …

A 73-year-old man with recent cognitive decline jumped from a cruise ship in Western Australia, resulting in death. Clinical lessons include recognising that cognitive impairment and depression may manifest as behavioura…

diagnostictemazepam
WAhospital2015-02-26

Inquest into the Death of Peta Susan DOIG

58y · Female·pneumonia and cardiac failure complicated by hypoxic brain injury

A 58-year-old woman with autism and severe intellectual disability died from pneumonia and cardiac failure complicated by hypoxic brain injury following cardiac arrest. She had been institutionalised at Graylands Hospita…

psychiatryintensive carediagnosticdelayazithromycin
WAhospital2015-02-26

Inquest into the Death of John Vincent KEARNEY

49y · Male·Carbon monoxide toxicity

John Vincent Kearney, 49, with a history of depression and previous suicide attempt presented to Sir Charles Gairdner Hospital ED on 26 March 2010 with suicidal ideation triggered by work stress. Psychiatric clinicians c…

psychiatryemergency medicineantidepressant
WAmental health2015-02-26

Inquest into the Death of Tracy Margaret MARSHALL

47y · Female·Ligature compression of the neck (suicide by hanging)

Tracy Margaret Marshall, a 47-year-old woman admitted to Nickol Bay Hospital as a voluntary patient due to deteriorating mental state and suicidal ideation, left the hospital on 21 February 2011. She drove to a remote lo…

psychiatrysystemdelay
WA2015-02-24

Inquest into the Death of Valfrids KLAVINS

65y · Male·complications of mesothelioma

Valfrids Klavins was a 65-year-old prisoner who died from mesothelioma complications on 9 January 2012 at Sir Charles Gairdner Hospital. He had been exposed to asbestos during his youth while working as a laborer. In Aug…

general practicecardiology
WAhospital2015-02-13

Inquest into the Death of Christopher Ling TAO

2y · Male·Myocarditis secondary to Kawasaki Disease

Christopher Tao, aged 2 years 9 months, presented to Princess Margaret Hospital ED with a 5-day fever, cervical lymphadenopathy, rash, conjunctivitis, and other features diagnostic of Kawasaki Disease (KD) on 7 September…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
WAPodcast2015-02-09

Inquest into the Death of Myosotis Julianna MORIARTY

68y · Female·acute gastrointestinal haemorrhage secondary to bilateral dental extraction

A 68-year-old woman on long-term warfarin therapy for a prosthetic aortic valve died from acute gastrointestinal haemorrhage following dental extraction. The dentist failed to obtain an INR test within 24 hours of the pr…

dentistrygeneral practicediagnosticcommunicationwarfarin
WA2015-01-15

Inquest into the Deaths of Mohammad NOOR and Mohammad HASSAN and Mr SABIBULLAH (SABIB ULLAH)

Male·Immersion (drowning) in the Indian Ocean

Three stateless Rohingya men from Myanmar seeking asylum died by drowning in the Indian Ocean off Christmas Island on 24-25 January 2013. After their vessel (SIEV580) broke down on 23 January 2013 near Christmas Island, …

WAhospital2015-01-15

Inquest into the Death of Petra ZELE

28y · Female·hypoxic brain injury following cardiac arrest in association with pulmonary hype…

Petra Zele, a 28-year-old woman, died from hypoxic brain injury following cardiac arrest due to acute pulmonary embolism superimposed on chronic thromboembolic pulmonary hypertension. She presented to Fremantle Hospital …

emergency medicinecardiologydiagnosticcommunicationyasmin
WAcommunity2015-01-08

Inquest into the Deaths of Steven Walter McLean and Shane Henry Wallam

21y · Male·Steven McLean: Head and Neck Injury (cervical spine separation from skull with b…

Two young Aboriginal men, Steven McLean (21) and Shane Wallam (20), died in a motor vehicle crash on 30 April 2011 near Carrabin, WA, while driving a stolen vehicle at dangerous speeds. Both were severely intoxicated by …

alcohol
WAhospital2014-12-30

Inquest into the Death of Gheorghe Gruici

71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…

Gheorghe Gruici, a 71-year-old life-sentenced prisoner, died of organ failure from chronic renal failure, infective endocarditis, and chest infection. Over 15 years in custody, he developed multiple comorbidities includi…

general medicinenephrologyomeprazole
WAcommunity2014-12-30

Inquest into the Death of Gyan Murray JEFFERY

31y · Male·Head and chest injury

Gyan Murray Jeffery, age 31, died from head and chest injuries sustained when struck by two motor vehicles on the South Western Highway at Argyle, Western Australia, on 30 September 2011. He had a longstanding history of…

psychiatryemergency medicinemethamphetamine
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