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NSWhospital2016-10-26

Inquest into the death of Audrey MacGREGOR

88y · Female·combined effects of an overdose of hydromorphone and complications of pneumonia …

An 88-year-old woman with chronic lung disease, heart disease, and recent pneumonia following faecal transplant for clostridium difficile colitis was prescribed 0.5 mg hydromorphone subcutaneously for respiratory distres…

cardiologyrespiratory medicinemedicationcommunicationhydromorphone
NSWaged care2016-10-20

Inquest into the death of Savvas Epsimos

84y · Male·Complications of large right subdural haematoma

An elderly man with cognitive impairment and multiple comorbidities fell out of bed at an aged care facility while an assistant in nursing (AIN) was absent obtaining equipment. The AIN had raised the bed to facilitate us…

geriatric medicineemergency medicineproceduralcommunication
NSWcommunity2016-10-13

Inquest into the disappearance and suspected death of Andrew Russell

23y · Male·Not established; death is suspicious but manner and cause undetermined

Andrew Stephen Russell, a 23-year-old man with chronic liver disease receiving disability support, disappeared on 2 June 2009 from Bathurst, NSW. He was last seen leaving a house intending to go to a hotel. His complete …

NSWhome2016-09-30

Inquest into the death of Terry Riordan

45y · Male·multi-drug toxicity from ingestion of methadone and amitriptyline

Terry Riordan, 45, died from multi-drug toxicity caused by ingesting amitriptyline and methadone in April 2015. He had complex medical and psychiatric comorbidities, substance abuse issues, and was under care of his GP D…

general practicepsychiatrymedicationdiagnosticmethadone
NSW2016-09-14

Inquest into the death of Rodney James BATES

55y · Male·Traumatic brain injury caused by blunt force to the head sustained in a fall

Rodney Bates, a 55-year-old in custody at Cessnock Correctional Centre, died from traumatic brain injury sustained in a fall on 2 April 2015. He had experienced recurrent unexplained loss of consciousness episodes from N…

neurosurgeryneurologymethadone
NSWhome2016-09-14

Inquest into the death of NA

0y · Male·Hypoxic ischaemic encephalopathy (brain damage) sustained during and just after …

A newborn died from hypoxic-ischaemic encephalopathy following a home birth without medical assistance. The mother had significant risk factors: hepatitis C, anaemia, and transverse fetal lie confirmed at 38+ weeks gesta…

general practiceobstetricscommunicationsystem
NSW2016-09-12

Inquest into the death of M

15y · Female·hypoxic brain damage due to multiple drug toxicity

A 15-year-old girl in out-of-home residential care died from accidental overdose of heroin and methylamphetamine (speedballing) in her bedroom while a known drug user was present. She had complex trauma from childhood ab…

emergency medicinetoxicologydelaysystemheroin
NSWmental health2016-09-07

Inquest into the death of Miriam MERTEN

Female·traumatic and hypoxic brain injury caused by numerous falls and self-beating of …

Miriam Merten died from traumatic and hypoxic brain injury sustained during 25+ falls while in seclusion in a mental health unit. Critical clinical failures occurred: she was not provided one-to-one observation during th…

psychiatrycommunicationproceduralpsychotropic medications
NSWcommunity2016-08-26

Inquest into the death of Stacy Lee HUTCHINS

25y · Female·head injury sustained when she fell from a moving truck

Stacey Lee Hutchins, 25 years old, died from severe head injuries sustained when she fell from a moving truck driven by her former partner, Dean Willett, on 5 June 2007. The death followed her abduction at knifepoint by …

communicationsystem
NSW2016-08-19

Inquest into the disappearance and suspected death of Cheryl ARDLER

40y · Female·Medical cause cannot be determined; manner of death: homicide by person(s) unkno…

This coronial finding concerns the disappearance and suspected death of Cheryl Ardler, an Aboriginal woman who was reported missing on 26 June 2013 but is believed to have died between 5-25 December 2012. The evidence es…

NSW2016-08-17

Inquest into the death of Vasko Boskovski

Unknown·multiple gunshot wounds, fired by a person or persons unknown

Vasko Boskovski died on 30 July 2013 at St George Hospital, Kogarah from multiple gunshot wounds inflicted by an unknown person or persons in this unsolved homicide. The coroner's inquest was held on 17 August 2016, some…

NSWhome2016-08-12

Inquest into the death of Helen Dawson also known as Marcia Helen Key

75y · Female·Gunshot wound to the head

This case involves the homicide of a 75-year-old woman, Helen Dawson, who was shot through her front door at her residence. This is not a medical or clinical case; rather, it is a criminal homicide investigated by police…

NSWcommunity2016-08-11

Inquest into the death of Afif Fakhouri

37y · Male·Combination of methylamphetamine toxicity and restraint leading to physiological…

A 37-year-old man died after being physically removed and restrained by NSW TrainLink staff at Cootamundra Station. He was displaying erratic, agitated behaviour consistent with methylamphetamine intoxication and possibl…

emergency medicineforensic medicineproceduralcommunicationmethamphetamine
NSW2016-08-09

Inquest into the disappearance and suspected deaths of Elaine JOHNSON and Kerry Anne JOEL

Unknown·Not determined—presumed death on balance of probabilities, referred to Unsolved …

Elaine Johnson and Kerry Anne Joel were reported missing together in the Cronulla area in 1979 or 1980. After an inquest held in August 2016—36 years later—Magistrate Jerram made a finding, on the balance of probabilitie…

NSWhome2016-08-05

Inquest into the death of Robert Taylor

48y · Male·Cause of death remains unknown

Robert Taylor, a 48-year-old interstate truck driver, was found dead at his home on 10 June 2015. The autopsy was inconclusive, revealing only mild pulmonary congestion with no gross pathological abnormality, normal hist…

NSWhome2016-07-19

Inquest into the deaths of Benjamin Green and William Markee

32y · Male·Gunshot wound to the head (Benjamin Green: homicide by William Markee; William M…

This inquest examined the deaths of Benjamin Green (aged 32) and William Markee (aged 58) on 15 May 2015 in Nimmitabel, NSW. Markee shot Green in his sleep, then shot himself. Clinical lesson: Markee had clear, untreated…

psychiatrygeneral practicedelay
NSWhospital2016-07-15

Inquest into the death of Kevin Smith

66y · Male·Myelofibrosis with leukaemic transformation

Kevin Smith, aged 66, died in Long Bay Hospital while in custody serving a 17-year sentence for domestic violence and attempted murder. He had myelofibrosis with leukaemic transformation, emphysema, anaemia, and a congen…

palliative carehaematologymorphine
NSWcommunity2016-07-15

Inquest into the deaths of Susana Castillo, Liam Milne and Darren Milne

Unknown·Multiple injuries (road crash)

Three family members died on 1 February 2015 when a car was deliberately driven into a tree: Darren Milne (42), his wife Susana Estevez Castillo (39, pregnant), and their son Liam (11). Darren, an electrical engineer, pr…

psychiatrygeneral practicesystem
NSW2016-07-15

Inquest into the death of Sheila Drysdale

75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …

A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…

plastic and reconstructive surgerygeriatric medicinemedicationproceduralaspirin
NSWcommunity2016-07-12

Inquest into the death of Matthew Mitchell

30y · Male·head injury occasioned by impact with a moving vehicle moving at speed

Matthew Mitchell, 30 years old, died from a severe head injury sustained when struck by a moving vehicle on Graham Drive, Sandy Beach on 17 August 2013. He remained comatose for one month before dying at Royal North Shor…

trauma surgeryneurosurgeryalcohol
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