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NSWaged care2016-04-05

Inquest into the death of Patricia NORTHCOTE

76y · Female·Major organ failure secondary to sepsis due to gram-positive bacteraemia from ur…

Patricia Northcote, a 76-year-old paraplegic woman with advancing dementia, died from sepsis secondary to urinary tract infection complicated by a sacral pressure sore. The pressure injury developed in November 2012 at a…

geriatric medicinerehabilitation medicinediagnosticsystem
WAhome2016-02-15

Inquest into the Death of John Stephen PASSMORE

53y · Male·ligature compression of the neck (hanging)

John Stephen Passmore, a 53-year-old man with severe treatment-resistant paranoid schizophrenia, died by suicide while on community leave from psychiatric hospital. He had been an involuntary patient at Graylands Hospita…

psychiatryrehabilitation medicineolanzapine
NSW2015-11-27

Inquest into the death of Madeleine Duffy

18y · Female·asphyxiation and respiratory failure on a background of severe dystonic quadripl…

Madeline Duffy, 18 years old with severe dystonic quadriplegic cerebral palsy, died from asphyxiation and respiratory failure while in respite care. She was positioned on her side in bed with pillows, contrary to her usu…

rehabilitation medicineneurologycommunicationdelaybaclofen
VIChome2015-11-16

Finding into death of Leanne Margaret Patterson

52y · Female·gunshot wound to head

Leanne Patterson, 52, was shot and killed by her husband Neil in a murder-suicide on 5-6 January 2013. She had been sedated with clonazepam (prescribed to her husband) and zolpidem at the time of her death. The death occ…

general practicepain medicinecommunicationsystemclonazepam
VIChome2015-10-08

Finding into death of Edna May Pullen

93y · Female·Subdural haemorrhage in the setting of a fall (palliated)

A 93-year-old woman with a history of falls was discharged from hospital following treatment for subdural haematoma from a prior fall. Discharge planning included a home assessment by occupational therapy, during which t…

neurosurgerygeriatric medicine
VIChome2015-05-08

Finding into death of Divya Sharma

3y · Female·Homicide by chloroform exposure and/or smothering by father

Divya Sharma, age 3, died in April 2012 in Glen Waverley, Victoria, as part of a family homicide-suicide perpetrated by her father. The coroner found she was likely killed by chloroform exposure and smothering between 28…

rehabilitation medicineneurologydiagnosticcommunicationchloroform
VIChome2015-05-08

Finding into death of Divesh Sharma

5y · Male·unascertained

A 5-year-old boy and his sister (3 years old) and mother were killed by their father between 28-29 April 2012 in their Glen Waverley home. The father, who had experienced cognitive impairment and mood changes following a…

rehabilitation medicineneurologycommunicationsystemchloroform
VIChome2015-05-08

Finding into death of Preetika Sharma

35y · Female·homicide by smothering/suffocation, possibly facilitated by chloroform exposure

This tragedy involved the deaths of Preetika Sharma (35), her two children (Divesh, 5; Divya, 3), and her husband Nilesh, who killed his family and then himself. Mr Sharma exposed family members to chloroform before smot…

rehabilitation medicinegeneral practicediagnosticsystemchloroform
VIChome2015-05-08

Finding into death of Nilesh Sharma

36y · Male·Hanging (Mr Sharma); Homicide by smothering/suffocation or chloroform exposure (…

Nilesh Sharma, a 36-year-old Fiji Indian man, killed his wife Preetika, son Divesh (5 years old), and daughter Divya (3 years old) between 28-29 April 2012, then died by hanging. Evidence suggests he exposed them to chlo…

rehabilitation medicineneurologycommunicationsystemchloroform
VIChospital2014-11-17

Finding into death of Allan Phipps

76y · Male·exsanguination secondary to pulmonary aortic fistula and thoracic aorta aneurysm…

Allan Phipps was a 76-year-old man with a known thoracic aortic aneurysm and severe depression admitted to Austin Hospital in October 2012 for unstable angina and depression management. His aneurysm, discovered in March …

vascular surgerycardiologysystemdelayquetiapine
VICaged care2014-07-14

Finding into death of Vishna Mary Damke

54y · Female·Pneumonia and radiation induced brain injury

Vishna Damke, a 54-year-old woman with a long history of brainstem tumour treated with radiotherapy in 1994-1995, died of pneumonia complicated by radiation-induced brain injury. She had experienced progressive neurologi…

palliative careneurosurgerymorphine
VIChospital2014-03-17

Finding into death of Mervyn Barry Maslin

67y · Male·Complications arising from multiple injuries — fall from a height

A 67-year-old man died from complications of multiple injuries sustained in a fall from a 3-metre ladder while conducting home roof repairs in Tasmania. He fell forward through polycarbonate roofing onto a paved veranda …

neurosurgerytrauma surgerysystem
VICaged care2012-09-18

Finding into death of Brian Lench

58y · Male·Aspiration pneumonia in a man with a left middle cerebral artery stroke (palliat…

Brian Lench, a 58-year-old man with intellectual disability in DHS residential care, suffered a left middle cerebral artery stroke on 6 October 2011. He developed aspiration pneumonia complicated by acute respiratory dis…

emergency medicineneurologyantibiotics
VIChospital2012-03-06

Finding into death of TS

70y · Male·aspiration pneumonia and hypoxic brain injury in a setting of a man involved in …

A 70-year-old experienced painter suffered crush injuries to the neck when his head became pinned between a scissor lift platform and factory ceiling. He remained in vegetative state for three weeks before dying from asp…

intensive carerehabilitation medicinesystem
VICaged care2011-10-04

Finding into death of Shane Peter Kerstjens

42y · Male·Pulmonary thromboembolism and deep calf vein thrombosis

Shane Kerstjens, a 42-year-old man with cerebellar dystrophy and intellectual disability, died from pulmonary thromboembolism and deep vein thrombosis. He sustained a tibia and fibula fracture on 6 September 2007, requir…

orthopaedic surgeryrehabilitation medicinesystemdelayenoxaparin
VIC2011-07-28

Finding into death of Mr M

82y · Male·closed head injury (subdural haematoma) sustained in a fall

An 82-year-old man on warfarin died from a subdural haematoma sustained in a fall at a rehabilitation centre. He fell while attempting to walk to the toilet unassisted after not being provided with a urinal bottle, despi…

emergency medicineneurosurgerysystemdelaywarfarin
VICaged care2011

Finding into death of Mr CR

43y · Male·hypoxic brain injury secondary to asphyxiation by ligature

A 43-year-old man died from hypoxic brain injury due to asphyxiation by ligature while an inpatient at a rehabilitation centre. He had undergone spinal surgery for back pain and cauda equina syndrome but was failing to i…

neurosurgeryrehabilitation medicinecommunicationsystem
VICcommunity2010-10-19

Finding into death of Patrick Tolan

55y · Male·Multiple injuries sustained in a fall

Patrick Tolan, a 55-year-old man with chronic depression, alcohol dependence, and multiple suicide attempts, died from injuries sustained in a fall from a shopping centre sign. He had jumped from a parapet four years ear…

psychiatryorthopaedic surgerydiagnosticcommunicationmirtazapine
VICcommunity2010-01-14

Finding into death of Joeanne Maree Brady

39y · Female·Mixed drug toxicity (methadone, oxycodone, hydromorphone, mirtazapine, diazepam,…

A 39-year-old woman with chronic pain from a previous work injury died from mixed drug toxicity involving methadone, oxycodone, hydromorphone, diazepam, mirtazapine, and promethazine. Her pain specialist prescribed metha…

pain medicineneurologycommunicationmedicationmethadone
NThospital2009-11-27

Inquest into the death of Alma June Green

82y · Female·acute peritonitis, ruptured bowel and incarcerated bowel herniation

An 82-year-old woman admitted with bowel obstruction recovered well initially but suffered a preventable fall in the radiology department when left unattended with heavy IV pumps on her wheelchair, fracturing her hip. Af…

general surgeryradiologydiagnosticcommunicationoxycodone

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