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NSWhome2021-04-16

Inquest into the death of WW

Male·gunshot wound to the head, intentionally self-inflicted

WW died on 7 March 2016 at his residential address in Ingleburn, NSW, during a police siege. The coroner found that the death resulted from a gunshot wound to the head that was intentionally self-inflicted. This inquest …

psychiatryemergency medicinecommunicationsystem
NSW2018-09-28

Inquest into the death of TB and DP

34y · Female·Neck compression from ligature strangulation

This dual inquest examined deaths in Smithfield on 4 September 2016. A male partner (48) killed a female partner (34) while their three-year-old daughter was present. Separated but cohabiting, the couple's breakdown acce…

psychiatry
NSW2016-12-22

Inquest into the disappearance and suspected death of Suat Yildirimtekin

Male·Unknown; available evidence does not allow determination of cause

Suat Yildirimtekin disappeared on 8 October 1998 after being last seen by his mother in Parramatta and a business associate in Rydalmere. For nearly 18 years, an extensive police investigation found no evidence of his wh…

amphetamine
NSW2016-12-22

Inquest into the death of Brendan Hickey

34y · Male·Drowning by misadventure to which alcohol intoxication was a contributing factor

Brendan Hickey, a 34-year-old Irish immigrant, drowned in Cockle Bay, Darling Harbour on 23 May 2014 whilst intoxicated (BAC 0.256%) at the Vivid light show. He was unable to swim and fell from the boardwalk into 6.3m de…

systemcommunicationalcohol
NSWhospital2016-12-22

Inquest into the death of Shona Hookey

29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…

Shona Hookey, a 29-year-old Aboriginal woman with severe intellectual disability and aphasia, died of peritonitis secondary to bowel torsion. Critical failures occurred at multiple levels: carers at her group home delaye…

emergency medicineparamedicinediagnosticcommunicationparacetamol
NSWhospital2016-12-21

Inquest into the death Kyran DAY

0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…

Kyran Day, a 6-month-old boy, presented to Shoalhaven District Memorial Hospital with vomiting and lethargy on 19 October 2013. He was initially assessed and diagnosed with gastroenteritis based on recent rotavirus vacci…

paediatricsemergency medicinediagnosticcommunication
NSWhospital2016-12-20

Inquest into the death George TRIANTAFILOPOULOS

75y · Male·acute right subdural haemorrhage sustained in a fall

George Triantafilopoulos, a 75-year-old man on warfarin after aortic valve replacement, suffered two head strikes within 24 hours—first falling onto concrete at a supermarket on 14 August 2014, then falling onto concrete…

general practiceemergency medicinediagnosticdelaywarfarin
NSWaged care2016-12-16

Inquest into the death of Frederick PEISLEY

58y · Male·blunt force head injury

Frederick Peisley, an Aboriginal man with acquired brain injury and schizoaffective disorder, died from a head injury after falling from stairs at an aged care facility. Critical failures included poor communication of h…

psychiatrygeneral practicecommunicationsystempaliperidone
NSW2016-12-13

Inquest into the death of Blaine ROZS

19y · Male·Traumatic asphyxia

Blaine Rozs, 19, died from traumatic asphyxia after falling from a turf harvester while reversing. He was struck and crushed underneath the machine. Clinical lessons include: (1) traumatic asphyxia causes death within mi…

emergency medicineparamedicinesystemcommunication
NSWhome2016-12-08

Inquest into the death of Ezekiel HOWARD

10y · Male·Unascertained - sudden and unexpected death; evidence did not allow determinatio…

Ezekiel Howard, a 10-year-old boy, died suddenly in his sleep on 12 September 2011. His death remains unexplained despite extensive investigation. The coroner could not determine whether death resulted from undiagnosed e…

paediatricscardiologydiagnosticdelay
NSW2016-12-07

Inquest into the death of Michael GAVANAS

50y · Male·Acute methamphetamine toxicity

A 50-year-old man with significant cardiac history (previous stenting) died from acute methamphetamine toxicity. He had consumed a high concentration of methamphetamine solution orally, resulting in a markedly elevated b…

toxicologycardiologymethamphetamine
NSW2016-12-05

Inquest into the death of Gunawan PANDIASAPUTRA

Male

This inquest concerns the disappearance of Gunawan Pandisaputra, reported missing in December 1997 after allegedly arriving in Australia in May 1992. Despite extensive investigations by Detective Sergeant Hogan from 2007…

NSWhome2016-12-01

Inquest into the deaths of Robert PASHKUSS and Stacey McMAUGH

Unknown·Head injuries inflicted with a blunt instrument by a person or persons whom the …

Robert Pashkuss and Stacey McMaugh were fatally beaten with a blunt instrument at their home on 5-6 January 2008. Both died from head injuries inflicted by unidentified assailant(s). Robert was a drug dealer considering …

forensic medicinemethamphetamine
NSWhome2016-11-24

Inquest into the death of Dr Beta Vandeville

46y · Female·acute mixed drug toxicity due to accidental self-administered drug overdose

Dr V., an obstetrician-gynaecologist trainee, died from acute mixed drug toxicity on 18 January 2013 following self-administration of multiple anaesthetic drugs (propofol, midazolam, fentanyl, alfentanil) via intravenous…

anaesthesiaobstetricssystempropofol
NSWhospital2016-11-22

Inquest into the deaths of Sandra BONEY, Norman BONEY and Roger John ADAMS

Organising pneumonia (Sandra Boney and Norman Boney); Organising pneumonia compl…

Three Aboriginal Australians from Walli Reserve (Sandra Boney, 40; Norman Boney, 46; Roger Adams, 37) died within two months in early 2015 following consumption of illegally home-distilled methanol-containing alcohol ('m…

toxicologyemergency medicinediagnosticdelaymethanol
NSW2016-11-14

Inquest into the death of AA

43y · Male·complications of thermal injuries

A 43-year-old man with a history of workplace injury, financial stress, and social isolation attended a workers compensation office in Newcastle carrying mineral turpentine and a cigarette lighter. After about 23 minutes…

psychiatryemergency medicine
NSWhospital2016-11-04

Inquest into the death of Hellen Marsh

50y · Female·Irreversible hypoxic brain injury sustained during surgery for meningioma resect…

Hellen Marsh, a 50-year-old woman with Fragile X Syndrome and a brain meningioma, died from irreversible hypoxic brain injury sustained during tumour resection surgery. Significant intraoperative blood loss (4,500ml esti…

neurosurgeryanaesthesiacommunicationmonitoring
NSW2016-11-04

Inquest into the death of Phillip Hughes

25y · Male·traumatic basal subarachnoid haemorrhage due to vertebral artery dissection

Phillip Hughes, a 25-year-old professional cricketer, died from traumatic basal subarachnoid haemorrhage caused by vertebral artery dissection after being struck on the neck by a cricket ball during a Sheffield Shield ma…

emergency medicineneurosurgerycommunicationsystem
NSWcommunity2016-11-01

Inquest into the death of Michael JOHNSON

27y · Male·traumatic asphyxia

Michael Johnson, 27, died from traumatic asphyxia after his car rolled on a rural property. He was trapped under the vehicle with the car's pillar compressing his chest. Bystanders called 000, and following operator inst…

emergency medicinepathology
NSWcommunity2016-10-28

Inquest into the disappearance and suspected death of Gaida COOTE

84y · Female·Unable to determine exact cause; likely misadventure, accident, or sudden health…

Gaida Coote, 84, disappeared from Ku-ring-gai Wild Flower Garden on 3 December 2014 while volunteering. Her body was never found. Critical delays occurred: when her daughter reported her missing on 4 December at 8:20pm, …

communicationsystem
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