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NSWaged care2020-02-11

Inquest into the death of Neville Clutton

78y · Male·complications of head injuries; antecedent cause: dementia

An 78-year-old man with dementia died from head injuries sustained in a push by his roommate, also with dementia, at an aged care facility. The deceased had multiple prior incidents with the aggressor starting in Novembe…

geriatric medicinegeneral practicediagnosticcommunicationrisperidone
ACThome2020-02-07

Inquest into death of RODNEY WAYNE RUDD

67y · Male·aspiration of gastric contents, due to morphine toxicity, in the context of bila…

A 67-year-old man with chronic pain, pancreatitis, osteoporosis and emphysema died from aspiration of gastric contents due to morphine toxicity. He had been prescribed opioid medications (MS-Contin and Ordine) by his GP …

general practicepain medicinemorphine
WA2020-02-05

Inquest into the Death of Tania Marie HODGKINSON

48y · Female·Ligature compression of the neck (hanging)

Tania Marie Hodgkinson, a 48-year-old Aboriginal woman, died by suicide via ligature compression while remanded at Bandyup Women's Prison on 23 March 2017. She had been admitted with heroin withdrawal symptoms, grief fro…

psychiatrypsychologycommunicationsystemheroin
VIChome2020-02-04

Finding into death of Bruce John Camp

70y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis

Bruce Camp, a 70-year-old man with intellectual disability living in residential care, died from pulmonary thromboembolus secondary to deep vein thrombosis. He presented to a general practitioner on 29 March 2019 with ab…

general practiceemergency medicinerisperidone
WAcommunity2020-02-03

Inquest into the Death of Jose DA SILVA

34y · Male·unascertained; most likely immersion after swimming at City Beach

Jose da Silva, a 34-year-old man with a history of schizophrenia and problematic alcohol use, disappeared on 30 April 2017 from Perth, Western Australia. The coroner found he died on or about that date, most likely from …

psychiatrygeneral practiceolanzapine
VIChome2020-01-31

Finding into death of X Y

27y · Female·Combined drug toxicity

XY, a 27-year-old woman, died from combined drug toxicity on 21–22 December 2016 at a friend's house in Melbourne. She had a history of opioid use, depression, and anxiety following a violent crime. She was enrolled in r…

general practiceaddiction medicinesystemmethamphetamine
VICcommunity2020-01-31

Finding into death of Francis John Stewart

38y · Male·Sepsis complicating bronchopneumonia and chest wall abscess in the setting of an…

A 38-year-old man with secondary adrenal insufficiency from childhood chemoradiation died from sepsis complicating a chest wall abscess and bronchopneumonia, precipitated by an adrenal crisis. He presented to his GP with…

general practiceendocrinologydiagnosticcommunicationprednisolone
VICaged care2020-01-30

Finding into death of Adele Di Quinzio

86y · Female·Sepsis complicating sacral decubitus ulceration in the setting of recent surgica…

Mrs Di Quinzio, an 86-year-old woman with multiple comorbidities, was discharged from hospital to a supported residential service (SRS) after hip fracture surgery. She required two-person assistance for mobility and was …

geriatric medicineorthopaedic surgerysystemcommunicationcefalexin
VIChome2020-01-29

Finding into death of Caitlin-Lei Alaya

44y · Female·Combined drug toxicity (elevated pregabalin, temazepam, oxazepam, ibuprofen, mel…

Caitlin-Lei Alaya, a 44-year-old woman with fibromyalgia, PTSD, depression and suicidal ideation, died from combined drug toxicity (elevated pregabalin, temazepam, ibuprofen, meloxicam). She survived a suicide attempt on…

general practiceemergency medicinemedicationsystempregabalin
QLDPodcast2020-01-24

Willersdorf, Maria

87y · Female·Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular hear…

An 87-year-old woman died following a CT-guided epidural injection at a private radiology clinic. Although she had undergone the procedure for spinal pain, the radiologist performed an epidural injection at the T12 level…

radiologypain medicinediagnosticproceduralbupivacaine
NSW2020-01-24

Inquest into death of MW

52y · Male·Hanging

MW, a 52-year-old man awaiting extradition to the United States, died by hanging in Parklea Correctional Centre on 5 May 2017. Upon reception screening, he denied suicidal ideation and scored 21/50 on the Kessler 10 scre…

general practicepsychiatrymirtazapine
VIC2020-01-15

Finding into death of Travis Lee Fernandez

35y · Male·Hanging

Travis Lee Fernandez, aged 35, died by hanging in custody at Dhurringile Prison in November 2014. He had sustained bilateral mandibular fractures in January 2014 treated with open reduction and internal fixation (ORIF). …

oral and maxillofacial surgeryemergency medicinecommunicationsystemmethadone
VIChome2020-01-14

Finding into death of A S

46y · Female·Combined drug toxicity in a woman found in a bath

A 46-year-old woman with borderline personality disorder and bipolar affective disorder type 2 died from combined drug toxicity. She had a long history of overdose attempts, often without clear suicidal intent, and was u…

psychiatrygeneral practicecommunicationsystemphentermine
TAShome2020-01-03

Coroner's Finding: Combes, Margot Janeece

47y · Female·pulmonary thromboembolus

A 47-year-old nurse suffered a workplace fall resulting in a left ankle fracture requiring below-knee immobilisation. She was managed conservatively with a temporary cast for one week, then a permanent plaster cast appli…

orthopaedic surgerygeneral practice
TAShospital2020

Coroner's Finding: Bond, Johnathon Lee

51y · Male·mixed prescription drug toxicity (amisulpride, diazepam and mirtazapine)

A 51-year-old man with schizophrenia, depression and early dementia died from mixed prescription drug toxicity (amisulpride, diazepam, mirtazapine) after a deliberate overdose. He had recently presented to hospital with …

psychiatryemergency medicinesystemdelayamisulpride
VIChome2020

Finding into death of Julian Victor Charles Bareuther

68y · Male·PLASTIC BAG AND NITROGEN GAS ASPHYXIA

68-year-old man with terminal, inoperable pancreatic cancer died by asphyxiation using a plastic bag and nitrogen gas. He sought access to Voluntary Assisted Dying (VAD) through his GP, Dr C., who assessed him as mentall…

general practicepalliative caresystem
VICaged care2020

Finding into death of Sharon Brown

54y · Female·COMPLICATIONS OF DEMENTIA

Sharon Brown, a 54-year-old ward of the state with dementia, intellectual disability, and epilepsy, died from complications of dementia including aspiration pneumonia. She was admitted to Monash Hospital in September 202…

general practicegeneral medicine
NSWhome2019-12-20

Inquest into the deaths of TC and SN

Female·Hanging

This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral…

paediatricspsychiatrycommunicationsystem
VIChome2019-12-13

Finding into death of Kyle Horne

19y · Male·Hanging

Kyle Horne, a 19-year-old with high-functioning autism, died by hanging on 15 March 2018 following relationship breakdown. He presented to his GP on 8 March 2018 requesting a Mental Health Care Plan, citing relationship …

general practicepsychiatrydiagnostic
NSWhospital2019-12-13

Inquest into the death of Luca RASO

13y · Male·Peritonitis secondary to ruptured gangrenous acute appendicitis

Luca Raso, a healthy 13-year-old boy, died from peritonitis secondary to ruptured gangrenous acute appendicitis after being misdiagnosed with viral gastroenteritis by his GP on two consultations (22 and 24 February 2017)…

general practiceemergency medicinediagnosticcommunication

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