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SA2004-03-25

Coroner's Finding: GILL David John

34y · Male·undetermined; possible drowning or shark attack

David John Gill, aged 34, fell overboard from a trimaran during an evening sail on 27 November 2002 near Outer Harbour, South Australia. Despite an extensive air and sea search with 98% probability of detection, he was n…

systemcommunication
SAhospital2004-02-13

Coroner's Finding: CUCUK Radomir

38y · Male·multi organ failure secondary to intestinal ischaemia from toxic megacolon relat…

A 38-year-old man with chronic schizophrenia died from multi-organ failure secondary to intestinal ischaemia caused by toxic megacolon from severe constipation. He was a detained patient on Clozapine and Oxybutamin, both…

psychiatryemergency medicineclozapine
SA2004-02-13

Coroner's Finding: DEWSON Brian Keith

33y · Male·hanging

Brian Dewson, a 33-year-old man with a 12-year history of drug and alcohol abuse, multiple psychiatric assessments (antisocial personality disorder, depression), and prior suicide risk designations died by hanging in Por…

psychiatrycorrectional healthsystemcitalopram
SAhospital2004-02-13

Coroner's Finding: WHITE Kevin Charles

57y · Male·aspiration pneumonia secondary to small bowel obstruction

A 57-year-old man with chronic schizophrenia, intellectual disability, and history of bowel obstruction presented with faecal vomiting and signs of shock. He was appropriately transferred to hospital where small bowel ob…

emergency medicinesurgeryquetiapine
SA2004-01-30

Coroner's Finding: WOODCOCK Gary William Burton

36y · Male·anaphylactic reaction due to multiple bee stings

Gary Woodcock, a 36-year-old chimney sweep, died from anaphylactic reaction to multiple bee stings (40-50 stings) sustained while working at height on a chimney at St Peter's College. He was unknowingly allergic to bee v…

proceduralsystem
SAhome2004-01-29

Coroner's Finding: ARANY Eva and Jeno

Eva Arany: gunshot wound to the neck; Jeno Arany: traumatic brain damage complic…

An elderly man with severe depression, suicidal ideation, and ongoing psychiatric risk was hospitalised twice in 2000 and discharged on antidepressant medication. Despite staff identifying he owned seven firearms and pos…

psychiatrygeriatric medicinecommunicationsystemparoxetine
SAhospital2003-12-19

Coroner's Finding: HAWKE Anne Elizabeth

33y · Female·Raised intracranial pressure secondary to thrombosis of the superior sagittal, t…

A 33-year-old woman presented with acute neurological symptoms (headaches, weakness, slurred speech, seizures) on 26 August 2000. Initial CT imaging showed focal haemorrhage with oedema; repeat CT after 50 minutes showed…

neurosurgeryradiologydiagnosticcommunicationoral contraceptive pill
SA2003-12-18

Coroner's Finding: LINDSAY Margaret

38y · Female·neck compression due to hanging

Margaret Lindsay, 38, died by hanging in Adelaide Women's Prison on 23 May 2001 whilst remanded in custody. She had a complex history of psychiatric illness, drug and alcohol abuse, and multiple suicide attempts. Despite…

psychiatrycorrectional healthcommunicationsystemdiazepam
SA2003-11-07

Coroner's Finding: GOLDSMITH Brenton Maurice

19y · Male·Head injury: depressed stellate (star-shaped) fracture of skull with diffuse sub…

A 19-year-old male died from severe head injury (depressed stellate skull fracture with subarachnoid haemorrhage) sustained when a stolen motorcycle he was riding struck a kerb while evading police on Port Road, Adelaide…

emergency medicinetrauma surgerycommunicationsystemalcohol
SA2003-11-06

Coroner's Finding: AITKEN Lauren Kady and AITKEN Callum Macdonald

Lauren Kady Aitken: severe cerebral trauma associated with extensive cranial vau…

This is not a medical case. Two children (aged 12 and 10) died in a motor vehicle accident on 9 January 2000 when their father's vehicle left the roadway and fell 26 metres down an embankment near Crafers, South Australi…

SAhospital2003-11-05

Coroner's Finding: MARTIN Julie Anne

38y · Female·peritonitis with septic shock secondary to perforation of the gastrointestinal t…

A 38-year-old woman in persistent vegetative state following anoxic encephalopathy from anaphylaxis during surgery died from peritonitis caused by perforation at the gastrostomy stoma site. The perforation likely occurre…

anaesthesiaemergency medicinediagnosticcommunicationsuxamethonium
SAcommunity2003-10-29

Coroner's Finding: NICHOLLS Geoffrey Douglas

41y · Male·Shotgun wound to the left side of the chest with laceration of the heart and hae…

Geoffrey Douglas Nicholls, aged 41, was shot by police during an armed incident at Oodnadatta, South Australia. He had a history of mental illness including depression with suicidal ideation, Bartter's syndrome (causing …

emergency medicinepsychiatrysystemdelay
SAschool2003-10-27

Coroner's Finding: CHAPMAN Michael James

16y · Male·Gunshot wound to the head

A 16-year-old boy with a 5-year history of depression, multiple suicide attempts, and suicidal ideation died by self-inflicted gunshot wound at school on 1 August 2001. He had been under psychiatric care for 10 months, p…

psychiatrygeneral practicediagnosticcommunicationcitalopram
SA2003-09-25

Coroner's Finding: GOROSTIAGA Jessica

8y · Female·Closed head injury

An 8-year-old girl died from severe closed head injuries sustained when a bouncy castle (inflatable amusement structure) was lifted by a sudden whirlwind and collapsed. The child fell from the structure during its flight…

systemprocedural
SAhome2003-09-25

Coroner's Finding: SAMMUT-SMITH Jason Peter

16y · Male·fresh water drowning

Jason Sammut-Smith, a 16-year-old boy, died by fresh water drowning on 1 December 2001. The coroner found extensive evidence of physical abuse inflicted over months, including numerous bruises, abrasions, and injuries co…

forensic medicineemergency medicinesystemdelaydiazepam
SAhospital2003-09-18

Coroner's Finding: NEWTON Ronald Luke

7y · Male·Hypoxic-ischaemic encephalopathy due to reflex cardiac arrest triggered by blunt…

A 7-year-old boy died from hypoxic-ischaemic encephalopathy following a motor vehicle collision. He was seated on an unanchored booster seat and wearing an adult seatbelt. During the collision, the unsecured booster seat…

intensive careemergency medicinesystem
SA2003-07-24

Coroner's Finding: Whyalla Airlines

21y·Double engine failure and ditching. Primary causes: left engine crankshaft fract…

On 31 May 2000, Piper Navajo Chieftain VH-MZK ditched in Spencer Gulf after two engine failures, killing seven passengers and the pilot, with one person missing. The coroner found that the right engine was damaged by end…

aviation medicinesystemprocedural
SAcommunity2003-05-27

Coroner's Finding: GILLIES Wayne John

45y · Male·Bullet wound to the head - self-inflicted

A 45-year-old man with recurrent major depression died by self-inflicted gunshot wound in April 2000. His psychiatrists documented recent suicidal ideation and unstable mental state but determined he was not actively sui…

psychiatrygeneral practicecommunicationsystemvenlafaxine
SAhospital2003-05-08

Coroner's Finding: PRATT Shirley May

66y · Female·acute necrotising haemorrhagic mediastinitis

Mrs Pratt, aged 66, underwent elective gastroscopy at Kapunda Hospital. During the procedure she heaved, and blood was noted at the gastro-oesophageal junction. She was discharged the same afternoon with pain, only to re…

surgerygeneral surgerycommunicationsystemfentanyl
SAhospital2003-04-24

Coroner's Finding: KERKMAN Johannes Leonardis Stephanes

75y · Male·Multi-organ failure due to sepsis secondary to hospital-acquired pneumonia

A 75-year-old man with Alzheimer's dementia who was detained under Mental Health Act orders died from multi-organ failure due to sepsis secondary to hospital-acquired pneumonia. He was admitted to Royal Adelaide Hospital…

general medicineneurologyaspirin
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