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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
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
WAhospital2020-09-04

Inquest into the Death of Malakai Matiu Ward PARAONE

0y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…

Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. …

emergency medicineintensive carediagnosticcommunicationparacetamol
WAcommunityPodcast2020-08-18

Inquest into the Death of Jessica Lesley JACKSON

18y · Female·multi-organ failure due to combined effects of environmental exposure (hyperther…

Jessica Jackson, 18, died from multi-organ failure due to combined hyperthermia and dehydration while weight-cutting for an amateur Muay Thai fight. She lost approximately 9 kg in the final week through water-loading, de…

emergency medicinesports medicinediagnosticsystem
WAhospital2020-08-13

Inquest into the Death of Susan Jessica Elsie WINDIE

22y · Female·bowel obstruction due to faecal impaction

Susan Windie, a 22-year-old with rare congenital abnormalities affecting bowel function, died from bowel obstruction due to faecal impaction complicated by abdominal compartment syndrome. She presented to Carnarvon Hospi…

gastroenterologygeneral practicecommunicationsystemfleet enema
WAhospital2020-06-03

Inquest into the Death of Michael Warren DYBALL

56y · Male·bronchopneumonia complicated by multiorgan failure and hypoxic ischaemic encepha…

Michael Dyball, a 56-year-old prisoner with chronic kidney disease, hepatitis C, and treated oropharyngeal squamous cell carcinoma, collapsed in his prison cell and suffered cardiopulmonary arrest on 28 April 2016. He di…

nephrologyoncologydarbepoetin alfa
WAhospital2019-12-20

Inquest into the Death of Child TJW

7y · Female·aspiration pneumonia leading to multi-organ failure in a female child with compl…

A child with severe cerebral palsy, hypoxic ischaemic encephalopathy, microcephaly and seizure disorder died of aspiration pneumonia leading to multi-organ failure. Born with severe perinatal brain injury, she had comple…

paediatricsneurologymorphine
WAhospital2019-11-21

Inquest into the Death of Child SH

5y · Male·aspiration pneumonia with terminal palliative care, in a male child with complex…

A 5-year-old boy with severe congenital myopathy and arthrogryposis died from aspiration pneumonia following terminal palliative care. He had multiple complex medical needs including unsafe swallowing, recurrent respirat…

paediatricsrespiratory medicinesystemmorphine
WAhospital2019-09-23

Inquest into the Death of Dylan James RILEY

16y · Male·pulmonary embolism secondary to nephrotic syndrome

Dylan Riley, a 16-year-old with steroid-responsive minimal change nephrotic syndrome, died from a massive pulmonary embolism (PE) on 1 August 2015. He presented to Rockingham Hospital with dyspnoea, hypoxia, tachycardia …

nephrologyintensive caredelayenoxaparin
WAPodcast2019-08-14

Inquest into the Death of Anita Jade BOARD

8y · Female·complications of multiple injuries sustained in motor vehicle crash

Eight-year-old Anita Board died from catastrophic brain injury sustained in a motor vehicle crash at Perth Motorplex on her first junior drag racing licensing attempt. Her dragster failed to slow adequately after the fin…

emergency medicineintensive caresystemprocedural
WAhospital2019-08-02

Inquest into the Death of Timothy James CHANDLER

52y · Male·multiple organ failure and pulmonary thromboemboli complicating generalised seps…

A 52-year-old man with longstanding refusal of medical care presented with severe cellulitis, sepsis, and previously undiagnosed heart failure secondary to sleep apnoea. He lacked capacity to consent to treatment due to …

emergency medicinegeneral medicine
WAhospital2019-07-30

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

7y · Male·cardiorespiratory failure in a child with cerebral palsy and epilepsy, with acut…

Child KT (Vinnie), age 7, died of cardiorespiratory failure from cerebral palsy and epilepsy after a prolonged hospital admission. He had complex medical needs including chronic respiratory disease, requiring PEG feeding…

paediatricsintensive caresystemmorphine
WAhospital2019-07-22

Inquest into the Death of Arthur James BONNEY

59y · Male·ischaemic heart disease in the context of acute-on-chronic kidney failure associ…

Arthur James Bonney, a 59-year-old prisoner with advanced cardiac disease, chronic kidney disease, and diabetes, underwent a CT scan with iodinated contrast on 30 July 2015 at Fiona Stanley Hospital. Critical failures oc…

radiologycardiologydiagnosticproceduraliodinated contrast medium
WAhospital2019-06-21

Inquest into the Death of Gerda Theresia DUNKEL

44y · Female·pulmonary thromboembolism in a woman with likely myeloproliferative neoplasm

A 44-year-old previously healthy woman with BMI 30.5 and minimal comorbidities (snoring, back pain, knee pain) underwent elective sleeve gastrectomy for weight loss. Nine days post-op she presented with splenic rupture r…

general surgerybariatric surgerydiagnosticcommunicationheparin
WAmental health2019-05-22

Inquest into the Death of Pamela Edith ASHLEY

64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…

A 64-year-old woman with bipolar disorder, severe obstructive sleep apnoea, obesity and diabetes presented with acute psychotic relapse following stress and sleep deprivation. Initially admitted to ED where she was sedat…

psychiatryemergency medicinecommunicationsystemchlorpromazine
WAhospital2019-05-13

Inquest into the Death of Daniel Josef ADWENT

44y · Male·gunshot wound to abdomen

A 44-year-old male died from a gunshot wound to the abdomen sustained during a police response to a domestic violence incident. He became aggressive, wielded a knife, and lunged at police after Taser and pepper spray fai…

emergency medicinegeneral surgerycommunicationdelay
WAhospital2019-03-12

Inquest into the Death of Lorna May WOODS

39y · Female·pulmonary thromboembolism due to deep vein thrombosis and sepsis due to pyelonep…

Lorna May Woods, 39, died from pulmonary thromboembolism due to deep vein thrombosis and sepsis secondary to pyelonephritis on a background of metastatic ovarian cancer. She presented to Joondalup Health Campus with uros…

emergency medicinepsychiatryheparin
WAcommunity2019-02-06

Inquest into the Death of Torran Jake THOMAS

15y · Male·Multiple organ failure associated with hyperthermia (heat stroke)

A 15-year-old rugby league player died from heat stroke during training on an extremely hot Perth summer evening (44.4°C). The coaching staff appropriately applied NRL heat guidelines in deciding to proceed with modified…

emergency medicineintensive carediagnosticdelay
WAcommunity2019-01-29

Inquest into the Death of Glenn William STRICKLAND

43y · Male·Complications of neck injury; specifically extensive brainstem infarction second…

Glenn William Strickland, an experienced Harley Davidson rider, died from brainstem infarction following severe cervical spinal injury sustained in a motorcycle crash on Julimar Road, Western Australia. He failed to nego…

emergency medicinetrauma surgerysystemdelay
WA2019-01-07

Inquest into the Death of Ali JAFFARI

Male·thermal injuries (burns)

Ali Jaffari, an immigration detainee, died by suicide at Yongah Hill Immigration Detention Centre on 16 September 2015. He sustained fatal thermal injuries from a fire he deliberately started in his room. The deceased ha…

psychiatrypsychologysystemolanzapine

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