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SA2000-03-02

Coroner's Finding: GRAETZ Anthony Roy

28y · Male·Traumatic brain damage complicating contact .22 calibre gunshot wound to the mid…

Anthony Roy Graetz, aged 28, died from a self-inflicted .22 calibre gunshot wound to the forehead during a police siege at his parents' property in Loxton, South Australia. In the months prior, he had displayed signs of …

forensic medicinepsychiatry
SAhospital2000-02-25

Coroner's Finding: STONEHOUSE Jarrod William (aka Scott)

23y · Male·aspiration of blood due to stab wound to trachea

23-year-old man with self-inflicted stab wound to neck presenting to emergency department while intoxicated and agitated. Ambulance noted 3cm laceration to midline trachea with minimal external bleeding. Registered nurse…

emergency medicinesurgerydiagnosticcommunicationalcohol
WA2000-02-11

Inquest into the Death of Sean Kevin Hayes

24y · Male·plastic bag asphyxiation

Sean Kevin Hayes, a 24-year-old male remand prisoner, died from plastic bag asphyxiation in his cell at Canning Vale Remand Centre in Western Australia on 20-21 August 1997. He had a history of psychiatric illness, previ…

psychiatrycorrectional healthsystemcommunicationstelazine
SA2000-02-01

Coroner's Finding: DONOGHUE Tony

22y · Male·Multiple injuries sustained in a shark attack

A 22-year-old male windsurfer disappeared while windsurfing at Hardwicke Bay, South Australia on 29 May 1999. His sailboard was found undamaged, but his wetsuit and harness showed damage consistent with a great white sha…

WAmental health2000-01

Inquest into the Death of Steven Charles Indich

20y · Male·Ligature Compression of the Neck (Hanging)

Steven Charles Indich, a 20-year-old Aboriginal man with schizophrenia and a long history of psychotic symptoms, violent behaviour and substance abuse, died by suicide in Smith Ward at Graylands Hospital on 13 November 1…

psychiatryintensive caresystemhaloperidol
NTcommunity1999-11-24

Inquest into the death of Gary Peter Tipungwuti, Patrick Raymond Kerinauia, Noeline Pauantulura, John Gerard Orsto

Unknown·Four deaths: three by self-inflicted hanging, one by multiple injuries from fall

Four Aboriginal Tiwi Islanders died in 1998 from suicide by hanging (three cases) and by falling from a power pole (one case). The inquest identified widespread alcohol and cannabis abuse, domestic violence, cultural dis…

alcohol
ACT1999-08-05

In The Matter Of An Inquest Into The Death Of Ian Glen Bransby At Canberra On 14.2.98

31y · Male·extensive global cerebral hypoxia following prolonged asphyxia following attempt…

Ian Glen Bransby, a 31-year-old remandee with a history of substance abuse and depression, died from asphyxia following attempted hanging at Calvary Hospital on 14 February 1998. He had been remanded at Belconnen Remand …

psychiatrygeneral practicecommunicationsystemchlorpromazine
ACT1999-06-28

Inquest Into The Manner And Cause Of Death Of Mark Robert Watson

17y · Male·Cerebral ischaemia caused by hanging at Quamby Youth Detention Centre at approxi…

Mark Watson, a 17-year-old boy charged with assault, was detained at Quamby Youth Detention Centre. During his second remand in September 1996, after a failed hospital admission, he returned to the same unit where he had…

psychiatrypsychologysystemsupervision
NThome1999-06

Inquest into the death of Clinton Leslie Kingsley

2y · Male·drowning

A 2-year-old Aboriginal boy drowned in an exposed septic tank at a remote community after plumbers removed concrete covers without installing replacements or notifying residents. The fibreglass lid's fastening screws had…

proceduralcommunication
ACTcommunity1999-02-26

In The Matter Of The Death Of Warren Geoffrey Ianson

Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…

Warren I'Anson died from gunshot wounds to the mid-back on 17 November 1995 during a police response to a mental health crisis. He had schizophrenia, recently experienced grief from his wife and friend's deaths, and was …

psychiatryemergency medicinecommunicationsystemdiazepam
ACTcommunity1999

Inquest Into The Death Of Katie Bender

12y · Female·Head injury caused by high-velocity steel fragment missile, approximately 999 gr…

Katie Bender, aged 12, was struck fatally in the head by a 999-gram steel fragment while watching the controlled implosion of Royal Canberra Hospital on 13 July 1997. The fragment travelled 430 metres in 3.1 seconds at 1…

occupational and environmental healthdiagnosticprocedural
NTcommunity1998-09-02

Inquest into the death of Esky Muller

14y · Male·Loss of blood arising from incised wound to the left arm (cubital fossa)

A 14-year-old Aboriginal petrol sniffer brought to a remote outstation (Ilpurla) without pre-arrangement died from massive haemorrhage following a self-inflicted laceration to his arm. Clinical lessons: petrol sniffers i…

emergency medicineaddiction medicinediagnosticsystempetrol
ACThospital1998-07-16

Inquest Into The Death Of Nathan Thomas James Wrench

0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…

Nathan Wrench, 11 weeks old, presented to Queanbeyan Hospital on 14 October 1996 with persistent vomiting for 3 days. GP Dr Renshaw diagnosed viral infection with possible reflux, admitted for observation, and managed co…

paediatric surgeryemergency medicinecommunicationdiagnostic
ACThome1998-03-06

Inquest Into The Circumstances Surrounding The Death Of Brian Joseph Duff

36y · Male·Toxic overdose of Clozapine (anti-psychotic drug), self-administered, with termi…

Brian Duff, a 36-year-old with severe chronic schizophrenia, died from Clozapine toxicity (pulmonary oedema and cardiac arrest) on 14-15 February 1997. He was subject to a Community Treatment Order and under case managem…

psychiatrycommunicationsystemclozapine
ACT1997

Inquest Into The Circumstances Surrounding The Death Of Shannon Robert Camden

21y · Male·Suffocation from hanging

Shannon Robert Camden, a 21-year-old with longstanding mental health difficulties and previous suicide attempts, died by hanging in cell A1 of the Belconnen Remand Centre on 15 April 1996 while on remand awaiting trial f…

psychiatrypsychologyproceduralsystem
TAShospital1996-10-01

Coroner's Finding: Muller Shar Marie

25y · Female·injuries sustained by jumping from the Tasman Bridge

A 25-year-old woman with longstanding borderline personality disorder, chronic suicidal ideation, and substance abuse died by jumping from the Tasman Bridge on 4 January 1996. She presented to the Emergency Department on…

psychiatryemergency medicinecommunicationsystemflunitrazepam
NTcommunity1995-12-13

Inquest into the death of Azaria Chantel Loren Chamberlain

0y · Female·unknown

This coronial finding concerns the death of Azaria Chamberlain, a 9-week-old infant who disappeared from a tent at Ayers Rock on 17 August 1980. After her parents were convicted of murder and accessory after the fact (la…

pathologyforensic medicine
NT1994-12-20

Inquest into the death of T. Okano, A. Kabe, T. Linklater and K. Pritchard (Cannonball Run)

Kabe 40, Okano 35, Linklater 22, Pritchard 31y · Male·Kabe and Okano: blunt head injury (head-to-head collision of occupants within ve…

On 24 May 1994, Ferrari F40 driver Akihiro Kabe entered a checkpoint lay-by at excessive speed (>100 kph, possibly 150 kph) following the 87.3 km mark where he mistakenly believed the checkpoint was located. The Ferrari …

emergency medicineforensic medicinedriver errorsystem error
NTcommunity1991-06-03

Inquest into the death of Ganamu Garrawurra

48y · Male·shotgun wound to the head

A 48-year-old Yolngu man with chronic mental illness (schizophrenia) died from a shotgun wound to the head on Elcho Island, NT in April 1990. After spearing two people with a fishing spear, police Task Force was called t…

psychiatryforensic medicinesystemcommunicationmelleril
NSWcommunity1990-07-18

Newcastle earthquake 1989 findings and recommendations

Multiple traumatic injuries sustained in earthquake-induced building collapse; o…

The 28 December 1989 Newcastle Earthquake (magnitude 5.6) killed 13 people: 9 in the Newcastle Workers Club collapse and 3–4 from Beaumont Street building failures. The coroner found that while the 1972 Club extensions l…

emergency medicine

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