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WAaged care2013

Inquest into the Death of Webb, Violet

83y · Female·Diffuse Alveolar Damage in a woman with recent leg fracture and Atherosclerotic …

An 83-year-old woman with diabetes, cardiovascular disease, and mobility limitations fell from her bed while on a bedpan at an aged care facility, sustaining a compound ankle fracture. The registered nurse on duty had le…

geriatric medicineorthopaedic surgeryproceduralsystemfentanyl
WAhospital2013

Inquest into the Death of Williams, Ronald Graham

52y · Male·Coronary Atherosclerosis

Ronald Graham Williams, a 52-year-old sentenced prisoner with known cardiovascular disease, previous myocardial infarction, dyslipidaemia, hypertension, and type 2 diabetes, died of coronary atherosclerosis at Swan Distr…

emergency medicinecardiology
WAhospital2013

Inquest into the Death of Zappacosta, Palmerino

86y · Male·Sepsis associated with a pericolic abscess, complicated by terminal large intest…

An 86-year-old life-sentenced prisoner died from sepsis associated with a pericolic abscess complicated by terminal gastrointestinal haemorrhage. He had extensive comorbidities including bilateral amputations, cardiac fa…

emergency medicinegeneral medicinevenlafaxine
WAhospital2012-10-05

Inquest into the Death of Rasmussen vaughn

15y · Male·Cerebral ischaemia in a young man with a blocked ventricular peritoneal shunt an…

Vaughn Richard Rasmussen, a 15-year-old boy with congenital abnormalities and a ventricular-peritoneal (VP) shunt, died from cerebral ischaemia caused by acute blockage of his VP shunt on 17 November 2009. Between 12-16 …

general practicegeneral medicinediagnosticcommunicationlamotrigine
WAhospital2012-09-14

Inquest into the Death of dawkins

17y · Female·Acute Lymphocytic Meningitis and Focal Myocarditis

Amy Lee Dawkins, 17, presented twice to Rockingham General Hospital ED within two weeks with severe headaches, myalgias, and vomiting. On 28 December 2008, she was discharged with a diagnosis of viral upper respiratory t…

emergency medicinegeneral medicinecommunicationsystemcitalopram
WAhome2012-09-07

Inquest into the Death of Mulvaney

54y · Female·Multi-organ failure following a decreased level of consciousness caused by compl…

Linda Christina Mulvaney, 54, died of multi-organ failure following a prolonged period of unconsciousness caused by a combination of obstructive and central sleep apnoea complicated by sedating substances. On 2 June 2008…

respiratory medicineintensive caredelaydiazepam
WAhospital2012-08-31

Inquest into the Death of Stone

62y · Female·Multiple injuries sustained from jumping from rocks at Torndirrup National Park …

Pamela Stone, a 62-year-old woman with a complex history of trauma, depression and relationship difficulties, presented to Albany Regional Hospital ED on 26 March 2009 after a violent altercation at home, having been sed…

emergency medicinegeneral practicesystemcommunicationmidazolam
WAhome2012-06-29

Inquest into the Death of Operation Lantana

Toxicity from intravenous caesium, DMSO, and other substances administered as pa…

In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr B.'s home in Perth, Western Australia, administering intravenous treatment containing caesium, DMSO, and La…

general practiceoncologydiagnosticproceduralcaesium chloride
WAhospital2012-06-27

Inquest into the Death of LEE

37y · Male·Respiratory arrest in association with medication drug effect and alcohol intoxi…

David James Lee, a 37-year-old Aboriginal man with schizophrenia, died on 15 July 2007 at Port Hedland Regional Hospital from respiratory arrest associated with medication effect and alcohol intoxication. He arrived at t…

emergency medicinepsychiatrymedicationcommunicationchlorpromazine
WAhospital2012-05-31

Inquest into the Death of GARRETT

52y · Male·HIV infection complicated by basal and squamous cell carcinoma of the head and n…

Bruce Jason Garrett, a 52-year-old prisoner detained under the Dangerous Sexual Offenders Act, died at Royal Perth Hospital on 2 October 2010 from HIV infection complicated by basal and squamous cell carcinoma of the hea…

emergency medicineintensive careheparin
WAhospital2012-05-18

Inquest into the Death of Allan

16y · Male·Pneumonia complicating influenza A (H1N1) infection with secondary Staphylococcu…

Andrew Allan, a 16-year-old student, died from pneumonia complicating influenza A (H1N1) infection with secondary Staphylococcus aureus septicaemia. He presented to Northam Regional Hospital Emergency Department on 16 Se…

emergency medicinegeneral practicediagnosticcommunicationmethylphenidate
WAhospital2012-04-05

Inquest into the Death of Little

0y · Female·perinatal pneumonia in association with meconium aspiration

Baby Sharinka Patricia Little, born prematurely at 35 weeks at Dalwallinu Hospital on 20 March 2008, died from perinatal pneumonia with meconium aspiration the same day. Critical clinical failures occurred during her nin…

neonatologygeneral practicediagnosticcommunication
WAhome2012-04

Inquest into the Death of BENFIELD

0y · Female·Unascertainable

Shar Rose Benfield, a 7-month-old Aboriginal infant born prematurely to parents with significant psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child …

paediatricspsychiatrysystemdelay
WAhospital2012-03-30

Inquest into the Death of Ellery

25y · Male·Ligature compression of the neck (hanging)

David Peter Ellery, a 25-year-old man with long-standing amphetamine addiction and deteriorating mental health, died by hanging on 31 July 2007. He presented to Bentley Hospital on 31 July with active suicidal ideation, …

emergency medicinepsychiatrycommunicationsystemamphetamine
WAhospital2012-03

Inquest into the Death of Troy

63y · Female·Intra-cerebral bleed secondary to thrombocytopenia in a person with prolymphocyt…

Josephine Troy, 63, died on 14 February 2006 at Bunbury Regional Hospital from an intracerebral bleed secondary to thrombocytopenia (platelet count of 1) arising from prolymphocytic leukaemia. She had been in remission f…

haematologyintensive carecommunicationdelaychemotherapy
WA2012-02-23

Inquest into the Deaths of SIEV 221 Victims (Christmas Island)

Drowning from immersion in the sea; for those whose bodies were not recovered, d…

SIEV 221, a fishing vessel carrying 92 people, sank on Christmas Island on 15 December 2010, killing 50 asylum seekers and crew. Thirty bodies were recovered; 20 remain missing. The vessel lacked adequate lifejackets, sa…

systemdelay
WA2012-01-12

Inquest into the Death of Brennan

38y · Male·Exsanguination due to penetration of arm veins

Declan Brennan, a 38-year-old sentenced prisoner at Acacia Prison due for release on 30 April 2008, died by suicide on 27 April 2008 from exsanguination due to penetrating wounds to his arm veins. Brennan had a long-stan…

psychiatrycorrectional healthsystemdelaylithium
WA2012

Inquest into the Death of Christmas Island Tragedy

27y · Female·Immersion (drowning) and injuries from impact with rocky shore and debris in the…

On 15 December 2010, the suspected irregular entry vessel SIEV 221 crashed on the rocky coastline of Christmas Island during the monsoon season in rough seas, resulting in 50 deaths—30 of whom were recovered and 29 ident…

systemdelay
WAhospital2012

Inquest into the Death of Keogh

38y · Female·Pulmonary Thromboembolism

Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…

general surgeryintensive carecommunicationdelaywarfarin
WAhospital2011-11-22

Inquest into the Death of Ashdown

27y · Male·cardiac arrhythmia during restraint; mechanism involved hypoxia and asphyxiation…

Warwick Andrew Ashdown, a 27-year-old male with severe treatment-resistant paranoid schizophrenia, died at Graylands Hospital on 12 October 2007 from cardiac arrhythmia during physical restraint. After assaulting another…

psychiatryintensive careproceduralsystemhaloperidol
134353644

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