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SAhome2001-08-28

Coroner's Finding: KERRISON Noel James

82y · Male·Carbon monoxide poisoning, contributing factor: ischaemic heart disease due to c…

An 82-year-old man died from carbon monoxide poisoning in his home. His gas cooker had a faulty regulator operating at 0.7 kPa instead of the required 1.0 kPa, causing excessive pressure drop when burners were activated.…

system
SAhospital2001-08-24

Coroner's Finding: GADALETA Saverio

28y · Male·Peritonitis and septic shock complicating perforation of the terminal small bowe…

A 28-year-old man with cerebral palsy, microcephaly, and epilepsy presented to the ED with abdominal pain, fever, and signs of deterioration. Triaged as Priority 3 despite these concerning features, he was not seen by a …

emergency medicinegeneral surgerycommunicationdelayparacetamol
SA2001-08-21

Coroner's Finding: IRVINE Samantha and SAKAMOTO Goro

26y · Male·Multiple injuries from mid-air aircraft collision

Two aircraft collided mid-air during gliding operations near Waikerie, South Australia. The Japanese glider pilot, Goro Sakamoto, failed to maintain adequate lookout and did not effectively use radio communication to ann…

communicationsystem
SAhome2001-07-16

Coroner's Finding: BRADY Mary

64y · Female·Haemorrhagic bronchopneumonia complicating doxepin overdosage

A 64-year-old woman died from doxepin overdose complicated by haemorrhagic bronchopneumonia. She had attempted suicide in April 1999 and was referred to a psychiatrist (Professor Schioldann) who prescribed sertraline. He…

general practicepsychiatrycommunicationmedicationdoxepin
SAhospital2001-07-13

Coroner's Finding: TRIMBOLI Jayden Tyler

0y · Male·hypoxic-ischaemic encephalopathy due to prolonged fetal bradycardia

Jayden Tyler Trimboli, aged 6 days, died from hypoxic-ischaemic encephalopathy caused by a prolonged fetal bradycardia episode between 11:10pm and 11:50pm on 18 September 1998. The critical failure was that the cardiotoc…

obstetricsmidwiferycommunicationsystemprostaglandin gel
SAcommunity2001-06-02

Coroner's Finding: MacLEOD Grant Alistair

38y · Male·Internal haemorrhage complicating large calibre gunshot wounds to the neck

Grant MacLeod, aged 38, died from a gunshot wound to the neck inflicted by Constable Mark Buckingham during a police response to reports of an armed person at a service station. MacLeod had suffered severe head injury in…

psychiatryforensic medicinesertraline
SAhospital2001-05-16

Coroner's Finding: HAMPTON Ronald Allen

77y · Male·respiratory failure caused by severe pneumonia

Ronald Allen Hampton, aged 77, died from respiratory failure due to severe pneumonia while detained under the Mental Health Act at Glenside Hospital. He had been admitted with behavioural disturbances related to dementia…

psychiatrygeneral medicineantibiotics
SAhospital2001-05-16

Coroner's Finding: KLOSE Glen Malcolm

71y · Male·Saddle pulmonary embolus as a consequence of deep venous thrombosis in the right…

Glen Malcolm Klose, aged 71, died from a saddle pulmonary embolus secondary to deep vein thrombosis in his right calf, a complication associated with his history of multiple knee surgeries. He was admitted to Glenside Ho…

psychiatrygeneral medicinedelay
SAhospital2001-05-16

Coroner's Finding: ROBERTS Brian Murray

76y · Male·respiratory failure secondary to right pneumonectomy and chronic obstructive air…

A 76-year-old man with a history of right pneumonectomy 25 years prior, chronic obstructive airways disease, and recent-onset dementia was detained under the Mental Health Act at Glenside Hospital. On 21 May 2000, he col…

psychiatryrespiratory medicineantibiotics
SAhospital2001-05-04

Coroner's Finding: ROACH Dawn Ruth

45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…

A 45-year-old woman died from multi-organ failure following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (1.5 cm) was contained and re…

colorectal surgerygeneral surgeryproceduralcommunication
SAcommunity2001-02-02

Coroner's Finding: BAYES Cameron Smeaton

25y · Male·Multiple injuries from shark attack

A 25-year-old male from New Zealand died following a shark attack while surfing at Cactus Beach, South Australia on 24 September 2000. Multiple witnesses observed a large white pointer shark attack the deceased in approx…

SA2001-02-02

Coroner's Finding: WRIGHT Jevan

17y · Male·multiple injuries sustained in shark attack

A 17-year-old male surfer was attacked and killed by a large white pointer shark while surfing at Blackfellows Point near Elliston, South Australia on 25 September 2000. The attack occurred without warning in daylight co…

SAhome2001-01-12

Coroner's Finding: ROTHWELL Sandra Lee

34y · Female·incineration and inhalation of products of combustion from motorised wheelchair …

Sandra Lee Rothwell, aged 34, died from incineration and inhalation of combustion products when a fire started in her motorised wheelchair while she was at home. She had severe cerebral palsy and was completely dependent…

codeine
SAmental health2000-12-12

Coroner's Finding: FELSTEAD Christopher John

33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes

A 33-year-old man with major depressive disorder and multiple suicide attempts died by carbon monoxide poisoning after premature discharge from psychiatric inpatient care. He was admitted to Lyell McEwin Health Service o…

psychiatryemergency medicinediagnosticcommunicationcarboxyhaemoglobin
SAcommunity2000-12-11

Coroner's Finding: SABINO Joseph Manuel

36y · Male·Cardiac failure associated with intravenous methylamphetamine abuse and exertion

A 36-year-old man died from cardiac failure associated with intravenous methylamphetamine abuse and exertion. He had injected methylamphetamine and subsequently engaged in intense physical activity (running, climbing fen…

emergency medicineforensic medicinemethamphetamine
SA2000-12-04

Coroner's Finding: NOBELS Laurens Adrian Keith

29y · Male·hanging

A 29-year-old man remanded in custody at Adelaide Remand Centre died by hanging on 15 January 2000. At admission, he denied self-harm risk and psychiatric history; no warning signs were identified. He was found hanging f…

forensic medicineemergency medicinecommunicationsystem
SA2000-11-28

Coroner's Finding: FRODSHAM Renee

37y · Female·blunt head trauma with skull fractures

Renee Frodsham, aged 37, disappeared on 17 March 1980 near Whyalla, South Australia. Her remains were discovered in April 1997 at Sinclairs Gap following information provided by Jacqueline Abbott regarding confessions ma…

forensic medicine
SA2000-11-28

Coroner's Finding: STURT Royston Henry

58y · Male·hanging

A 58-year-old man remanded in custody awaiting trial died by hanging in prison. He had a history of depression treated with fluoxetine and was assessed by a forensic psychiatrist who found no evidence of depression or su…

psychiatrygeneral medicinecommunicationsystemfluoxetine
SAhospital2000-11-20

Coroner's Finding: MIDDLETON Geraldine Ruth

45y · Female·haemorrhage due to traumatic rupture of the liver

A 45-year-old woman with a long history of bipolar disorder and personality disorder presented to the ED at 2:30 AM after cutting her wrist deeply with a carving knife. The treating casualty officer did not properly docu…

emergency medicinepsychiatrydiagnosticcommunicationdiazepam
SA2000-11-17

Coroner's Finding: BENSON Damien Alan

15y · Male·salt water drowning

Damian Alan Benson, aged 15, died by salt water drowning in the Southern Ocean near Carpenter Rocks, South Australia on 26 July 1998 during a fishing trip with his father. They departed in a 25-30 year old dinghy with a …

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