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ACThome2020-02-07

Inquest into death of RODNEY WAYNE RUDD

67y · Male·aspiration of gastric contents, due to morphine toxicity, in the context of bila…

A 67-year-old man with chronic pain, pancreatitis, osteoporosis and emphysema died from aspiration of gastric contents due to morphine toxicity. He had been prescribed opioid medications (MS-Contin and Ordine) by his GP …

general practicepain medicinemorphine
ACThome2019-12-10

Inquest into the death of Penelope Ann BLUME

68y · Female·Plastic bag asphyxia with vitiated atmosphere, with Motor Neuron Disease being a…

A 68-year-old woman with Motor Neuron Disease died from asphyxia on 15 March 2019. She had been diagnosed with MND in 2016 and experienced progressive disability requiring wheelchair use and assistance with activities of…

general practicepalliative care
ACThospital2019-11-22

Inquest into death of JAMIE LAWRENCE MITCHELL

36y · Male·Septicaemia and cerebral artery air embolism, due to complications related to cl…

Jamie Lawrence Mitchell, 36, died from septicaemia and cerebral artery air embolism complicating radiofrequency ablation for atrial fibrillation. He developed an atrioesophageal fistula after cardiac ablation at Royal Ad…

cardiologycardiothoracic surgerydiagnosticdelay
ACThospital2019-11-06

Inquest into death of THEADORA ZAAL

75y · Female·cardiac arrest in the context of aortic stenosis (moderate to severe), coronary …

A 75-year-old woman with significant cardiac history (aortic stenosis, coronary artery disease, left ventricular hypertrophy) underwent elective ankle ulcer debridement surgery. She developed refractory hypotension post-…

anaesthesiasurgerydiagnosticsystem
ACThospital2019-11-04

Inquest into death of JEFFREY BROWN

72y · Male·Haemopericardium due to anti-coagulation treatment for pulmonary thromboemboliti…

Jeffrey Brown, a 72-year-old with recent cardiac surgery (CABG), died from haemopericardium due to anticoagulation treatment for pulmonary thromboembolism. Post-mortem examination revealed fibrinous pericarditis (a known…

cardiothoracic surgerycardiologywarfarin
ACTcommunity2019-10-28

Inquest into death of John Wayne Woods

Male·multiple and massive, unsurvivable lethal injuries sustained as a result of a mo…

John Wayne Woods died in a motor vehicle collision on the Monaro Highway when his vehicle crossed onto the wrong side of the road and collided with an oncoming truck. While the dashcam footage raised the possibility of d…

ACTcommunity2019-10-14

Inquest into the death of Adrian Pitman

54y · Male·Multiple injuries due to motor vehicle collision with retaining wall caused by d…

Adrian Pitman, a 54-year-old man with treatment-resistant schizophrenia, died by suicide following a motor vehicle collision with a retaining wall. He was subject to a psychiatric treatment order and had 33 different cas…

psychiatrycommunicationsystemolanzapine
ACThome2019-09-23

AN INQUEST INTO THE DEATH OFJANDY RENIA SHEA

27y · Female·neck compression (suicide by hanging)

Jandy Renia Shea, 27, died by suicide by hanging on 4 March 2018 after a history of depression, anxiety, and previous suicide attempts following childhood sexual assault at age 16. She had recently reconciled with her es…

ACThome2019-09-20

Inquest into death of Kurt Mellick Andriske

52y · Male·septicaemia caused by Streptococcus Milleri group pneumonia

Kurt Mellick Andriske, 52, died from septicaemia caused by Streptococcus Milleri pneumonia, with drug toxicity as a contributing factor. He was a complex patient with bipolar disorder, chronic pain, hepatitis B and C, an…

general practicepsychiatrydiazepam
ACThospital2019-08-22

Inquest into death of Sebastian Nicholas Pelle

20y · Male·sudden unexplained death in epilepsy (SUDEP); right frontal lobe epidermal cyst …

A 20-year-old man with a history of seizures and a previously resected frontal lobe cyst presented to hospital with severe headaches. Despite his significant medical history of epilepsy and prior neurosurgery, he was dis…

neurologyemergency medicinediagnosticdelayparacetamol/codeine
ACThome2019-07-31

Inquest into the death of Cheyse Williams-Empson

3y · Male·unascertained

A 3-month-old boy died with an unascertained cause after being found unresponsive in his bassinet with a blanket covering his mouth and face. His mother had ongoing heroin use throughout pregnancy and postnatally, concea…

neonatologyforensic medicinecommunicationsystemheroin
ACT2019-06-27

Inquest into the death of Shane Robert Senini

51y · Male·Multiple injuries caused by the accidental explosion of acetylene gas in a seale…

Shane Robert Senini, a 51-year-old refrigeration mechanic, died from multiple injuries sustained in an accidental explosion at a school car park. He inadvertently failed to fully close the valve on an acetylene cylinder …

system
ACT2019-06-26

Inquest into the death of Mark Anthony O’Connor

40y · Male·Multiple drug toxicity, being either an overdose due to methylamphetamine alone,…

Mark Anthony O'Connor, a 40-year-old detainee with longstanding polysubstance use disorder, died in custody from multiple drug toxicity (methylamphetamine and possibly buprenorphine) on 13 May 2017. He self-administered …

emergency medicinetoxicologymethamphetamine
ACThospital2019-06-25

Inquest into the death of Jay Alan Paterson

43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …

Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone table…

general practicepain medicinesystemproceduraloxycodone
ACThome2019-06-20

AN INQUEST INTO THE DEATH OFMARK ANTHONY O’BRIEN

58y · Male·Heroin toxicity

58-year-old man with chronic back pain, paranoid schizophrenia, and decades-long prescription opioid and benzodiazepine abuse died from heroin toxicity. He had been successfully withdrawn from opioids (MS Contin, Endone)…

psychiatrypain medicinesystemcommunicationheroin
ACThome2019-06-04

Inquest into the death of Lauren Maree Johnstone

48y · Female·Combined toxic effect of prescription and non-prescription medications including…

Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…

general practicesurgerycommunicationsystemdoxylamine
ACTcommunity2019-02-28

Inquest into the death of Michael Richard Hall

Male·head and other injuries suffered when struck by a car while riding bicycle on Mo…

Michael Hall, an experienced ultra-endurance cyclist competing in the Indian Pacific Wheel Race, was struck and killed by a car on the Monaro Highway near Canberra at 6:20am on 18 March 2017 while riding in darkness. The…

system
ACT2019-02-15

AN INQUEST INTO THE DEATH OF BEN CATANZARITI

21y · Male·Head injuries suffered as a result of being struck by a concrete pouring boom wh…

Ben Catanzariti, 21, died from severe head trauma when struck by a collapsing concrete pump boom at a construction site in Kingston, ACT on 21 July 2012. The boom collapse resulted from failure of slew ring bolts securin…

system
ACThome2018-12-20

Inquest into the death of Lesley Kaye Hasleby

61y · Female·respiratory failure consistent with end-stage chronic obstructive airways disord…

A 61-year-old woman with chronic obstructive airways disease, liver disease, depression, and alcohol dependence died from respiratory failure. Her general practitioner prescribed a contraindicated combination of central …

general practicerespiratory medicinediagnosticcommunicationdosulepin
ACThome2018-11-29

AN INQUEST INTO THE DEATH OF TANIA LOUISE KLEMKE

46y · Female·Multiple significant injuries with associated exsanguination caused by a determi…

Tania Klemke, 46, died from exsanguination due to multiple severe dog bite wounds inflicted by her own Staffordshire Terrier cross, Simba, during an attack on 25 October 2017. The dog had a documented history of aggressi…

methamphetamine

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