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SAcommunity2009-08-17

Coroner's Finding: TURNER Brian Raymond

59y · Male·ischaemic heart disease due to coronary atherosclerosis

Brian Raymond Turner, 59, died from ischaemic heart disease due to coronary atherosclerosis following an out-of-hospital cardiac arrest in a medical clinic car park. He experienced symptoms of chest discomfort and breath…

cardiologyemergency medicinecommunicationdelay
SAhospital2009-08-12

Coroner's Finding: HOPE Maria Kate

55y · Female·hypoxic brain injury complicated by aspiration pneumonia

A 55-year-old woman with chronic schizophrenia died from hypoxic brain injury after suffocating herself with a plastic bin liner while hospitalised in a rural hospital. She was admitted following a disturbance where she …

general practicepsychiatrycommunicationdiagnosticolanzapine
SAhospital2009-08-07

Coroner's Finding: LAWRENCE Peter David

47y · Male·glioblastoma of the brain (glioblastoma multiforme, left frontal lobe)

Peter David Lawrence, aged 47, died from glioblastoma multiforme at Lyell McEwin Hospital. His brain tumour in the left frontal lobe caused behavioural changes including aggression, confusion, agitation and poor impulse …

palliative carepsychiatryhaloperidol
SA2009-08-07

Coroner's Finding: SCIACIA Marcielo Marstroianani

29y · Male·acute neck compression due to hanging

A 29-year-old Maori man died by hanging in Adelaide Remand Centre while in custody awaiting trial for domestic violence assault. He had been increasingly distressed about separation from his children and made multiple ph…

systemcommunication
SAhospital2009-07-30

Coroner's Finding: BRUNT Sidney

65y · Male·acute right subdural haematoma

Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…

general practiceemergency medicinemedicationcommunicationwarfarin
SAcommunity2009-06-30

Coroner's Finding: SALAGARAS Steven

56y · Male·effects of heat exhaustion

Steven Salagaras, a 56-year-old charity collector, died from heat exhaustion on 22 January 2006 after working in extreme heat (40.8°C) during a heatwave. He was observed appearing physically distressed while collecting d…

occupational and environmental healthforensic medicinesystemdelay
SAaged care2009-06-26

Coroner's Finding: DAVIES Harold Leslie

87y · Male·multi organ failure due to septic shock complicating urinary tract infection and…

An 87-year-old man with atrial fibrillation on warfarin developed septic shock and multi-organ failure following traumatic bladder catheterisation. Two catheterisation attempts occurred on 15 July 2005: an unsuccessful a…

general practiceurologyproceduralcommunicationwarfarin
SAhospital2009-06-24

Coroner's Finding: LINNELL Sienna Jools

0y · Female·Group B Streptococcus infection

A 7-hour-old neonate died from early-onset Group B Streptococcus (GBS) infection contracted during labour. The mother's GBS screening test at 35-37 weeks gestation was reported negative, and no antibiotic prophylaxis was…

obstetricsgeneral practicesystemcommunication
SAhome2009-06-04

Coroner's Finding: PROBY Zak Dean

27y · Male·combined effects of penetrating injuries (crossbow arrows) to heart and brain

Zak Dean Proby, 27-year-old Aboriginal male, died from penetrating injuries from crossbow arrows to the heart and brain during a police siege on 21 June 2006. He had exhibited paranoid and disturbed behaviour for 9 days …

emergency medicinegeneral practicecommunicationmarijuana
SA2009-06-03

Coroner's Finding: GROOTVELD Gerard

75y · Male·disseminated carcinoma of the prostate gland

Gerard Grootveld, a 75-year-old prisoner, died from disseminated prostate cancer with bone metastases. Sentenced in July 2006 despite known advanced cancer and multiple comorbidities, his health rapidly deteriorated in c…

palliative carecorrectional health
SAhospital2009-05-22

Coroner's Finding: ROBERTS Jarrad Delroy

10y · Male·sepsis (fusobacterium necrophorum) complicating right otitis media

Jarrad Roberts, a 10-year-old with learning disabilities and likely ADHD, died from sepsis due to untreated right otitis media caused by Fusobacterium necrophorum. He had been acutely ill for 5-7 days before finally seei…

paediatricsgeneral practicedelaysystemamoxicillin
SAhospital2009-05-21

Coroner's Finding: FARKAS Karl Derek

45y · Male·intracerebral haemorrhage caused by rupture of arterial aneurysm

A 45-year-old man with an intracerebral haemorrhage from a ruptured aneurysm presented to an emergency department and general practice on multiple occasions in October 2005 with headache, vomiting, dizziness, and neck st…

emergency medicinegeneral practicediagnosticcommunicationaspirin
SA2009-05-19

Coroner's Finding: O'KEEFFE Daniel William Barry

34y · Male·hypoxic encephalopathy following hanging

Daniel O'Keeffe, a 34-year-old male with amphetamine abuse and depression, died from hypoxic encephalopathy following hanging in Adelaide Remand Centre on 7 February 2007. He had attempted self-harm twice in custody afte…

psychiatryintensive caresystemcommunicationcitalopram
SAhome2009-04-17

Coroner's Finding: PARROTT Jenisha Diandra (aka White)

7y · Female·streptococcus pneumoniae sepsis complicating retropharyngeal abscess

A 7-week-old infant died from streptococcus pneumoniae sepsis complicating retropharyngeal abscess. Three days before death, a report was made to child protection services alleging the father had shaken the infants. A ge…

general practiceemergency medicinediagnosticsystem
SAcommunity2009-03-30

Coroner's Finding: DALLING Brian Terrance and SALOTTI Jack William and GRZYWACZ Richard John and SOBEY Brian Leslie

Male·acute myocardial infarction due to coronary artery disease (all four); specific …

Four rural South Australian men (aged 42-76 years) died from acute coronary syndrome in 2004-2006. All presented to country medical practitioners with symptoms suggestive of acute coronary syndrome but were not identifie…

general practiceemergency medicinediagnosticcommunicationaspirin
SAhospital2009-03-18

Coroner's Finding: COX Ricky Glen

17y · Male·refractory status epilepticus caused by either a viral infection, an underlying …

Ricky Cox, a 17-year-old Aboriginal youth in juvenile detention, died from refractory status epilepticus triggered by either viral infection or underlying epilepsy. On 2 February 2006, he became febrile and unwell at Cav…

neurologyemergency medicinesystemcommunicationdicloxacillin
SA2009-03-18

Coroner's Finding: ORTLEPP Joshua Luke

20y · Male·Hinge fracture base of skull and vault of skull fractures with closed head injur…

Joshua Luke Ortlepp, aged 20, died from skull fractures sustained in a motor vehicle collision while being pursued by police. He had consumed alcohol (BAC 0.179%) and cannabis, significantly impairing his driving ability…

alcohol
SAcommunity2009-03-18

Coroner's Finding: WANGANEEN John Frederick

29y · Male·multiple drug toxicity (buprenorphine, oxazepam, diazepam, alprazolam, and methy…

John Frederick Wanganeen, a 29-year-old with documented heavy polysubstance use, died of multiple drug toxicity after injecting crushed buprenorphine tablets mixed with water while on home detention bail. Critical system…

toxicologyforensic medicinecommunicationsystembuprenorphine
SAcommunity2009-03-06

Coroner's Finding: BRADFORD Steven Michael

20y · Male·severe blunt head trauma

Steven Bradford, a 20-year-old motorcyclist with a learner's permit, was riding an unregistered Honda CVR 600cc motorcycle illegally at high speed. After speeding on the Lincoln Highway, he was pursued by solo police off…

proceduralsystem
SAcommunity2008-12-18

Coroner's Finding: EDWARDS Adrian Lee

31y · Male·haemorrhage due to incised wound to left arm with amphetamine toxicity as a poss…

A 31-year-old man with personality disorder, possible epilepsy, possible schizophrenia, and polysubstance abuse made a triple zero call suggesting self-harm. Police and ambulance crews found him with a deep laceration to…

emergency medicineforensic medicinedextroamphetamine
131323346

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