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VIChome2019-12-11

Finding into death of Maddox Garry Wheeler

0y · Male·Unascertained

A 10-week-old boy born at 35 weeks gestation was found asleep on his mother's chest while she was asleep on a couch and died from an unascertained cause. Post-mortem toxicology detected methamphetamine and cannabis; the …

neonatologyobstetricscommunicationdelaymethamphetamine
ACThome2019-12-10

Inquest into the death of Penelope Ann BLUME

68y · Female·Plastic bag asphyxia with vitiated atmosphere, with Motor Neuron Disease being a…

A 68-year-old woman with Motor Neuron Disease died from asphyxia on 15 March 2019. She had been diagnosed with MND in 2016 and experienced progressive disability requiring wheelchair use and assistance with activities of…

general practicepalliative care
TAScommunity2019-12-06

Coroner's Finding: McInerney, Robert Edward

48y · Male·gunshot wounds to the right thigh and abdomen with fatal hemorrhage

A 48-year-old man with severe chronic pain, alcohol dependence, and mental health issues called police stating he was armed with knives and wanted to be shot. Despite being extensively supported by health services that d…

psychiatryemergency medicinealcohol
QLD2019-12-05

Harrison, Steven Leslie

61y · Male·Coronary atherosclerosis

Steven Harrison, aged 61, died of sudden coronary atherosclerosis while incarcerated at Wolston Correctional Centre. He had multiple cardiovascular risk factors including Type 2 diabetes, heavy smoking history, and intra…

cardiologygeneral practicediagnosticsystemmetformin
ACThospital2019-11-22

Inquest into death of JAMIE LAWRENCE MITCHELL

36y · Male·Septicaemia and cerebral artery air embolism, due to complications related to cl…

Jamie Lawrence Mitchell, 36, died from septicaemia and cerebral artery air embolism complicating radiofrequency ablation for atrial fibrillation. He developed an atrioesophageal fistula after cardiac ablation at Royal Ad…

cardiologycardiothoracic surgerydiagnosticdelay
NSWhospital2019-11-21

Inquest into the death of Ross MARTIN

56y · Male·acute pentobarbitone toxicity

Ross Martin, a 56-year-old man with a long history of depression, died from acute pentobarbitone (Nembutal) toxicity obtained online, combined with toxic levels of zopiclone, less than two weeks after premature discharge…

psychiatrygeneral practicediagnosticcommunicationpentobarbitone
NSW2019-11-08

Redacted findings in the joint inquest into deaths arising at music festivals including annexures - 8 November 2019

[18, 21, 23, 19, 22, 19]y · ["male", "female", "male", "male", "male", "female"]·MDMA toxicity (one case mixed MDMA and cocaine toxicity)

This inquest examined six deaths from MDMA toxicity after electronic dance music festivals in NSW between December 2017 and January 2019: Hoang Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), …

emergency medicineintensive carecommunicationproceduralMDMA
SAhome2019-10-29

Coroner's Finding: LATTUCA Christophe Thomas Bruno

34y · Male·neck compression due to hanging

A 34-year-old male on home detention bail died by hanging. He had a history of mental health issues, depression, and prior suicide threats, but did not disclose these to correctional services staff. In the 24 hours befor…

general practicepsychiatryalcohol
VICcommunity2019-10-29

Finding into death of Giuseppe Luci

51y · Male·Lobar pneumonia

Giuseppe Luci, a 51-year-old man with severe Fragile X syndrome, epilepsy and hearing impairment living in a DHHS group home, died from lobar pneumonia. On 29 October, he presented with vomiting and diarrhoea; a GP diagn…

general practiceemergency medicinediagnosticondansetron
NSW2019-10-25

Inquest into the death of R N

58y · Male·asphyxiation by ligature

A 58-year-old Cambodian male with basic English skills died by suicide in prison after 7 days in custody on remand for assault. Critical failures in the reception screening process included: incomplete identification and…

psychiatrycorrectional healthcommunicationsystem
NSWhospital2019-10-25

Inquest into the death of Peter SMITH

67y · Male·Gas gangrene with antecedent cause of Clostridium septicum septicaemia

Peter Smith, 67, presented to Cooma Hospital with severe leg muscle cramps and pain on 6 February 2018. Despite appropriate pain management and initial investigation suggesting rhabdomyolysis, he rapidly deteriorated and…

emergency medicinegeneral practicesystemmorphine
VIC2019-10-18

Finding into death of Mr A

24y · Male·Mixed drug toxicity

A 24-year-old man died from mixed drug toxicity after staying overnight at a backpackers hostel. He had a history of anxiety and shoulder pain following 2015 surgery, for which he received multiple medications including …

psychiatrygeneral practicecommunicationsystempregabalin
TAShome2019-10-16

Coroner's Finding: Powell, Stephen Maxwell

72y · Male·exsanguination (blood loss) from severed femoral artery

Stephen Maxwell Powell, a 72-year-old man with schizophrenia, died by exsanguination from a self-inflicted femoral artery laceration. He was discharged from psychiatric inpatient care on a community treatment order on 14…

psychiatrygeneral practicehaloperidol decanoate
VIC2019-10-16

Finding into death of FDS

34y · Male·Mixed drug toxicity

FDS, a 34-year-old male recently released from prison, died from mixed drug toxicity after injecting heroin in a public toilet. He had a long-standing complex drug history and relapsed shortly after release despite parol…

general practiceforensic medicinecommunicationdelayheroin
VICaged care2019-10-14

Finding into death of Grant White

65y · Male·Cardiomegaly

Grant White, a 65-year-old man with cardiomegaly and severe mitral regurgitation living in Department of Health and Human Services disability accommodation, died from cardiomegaly on 11 September 2017. Two days before hi…

cardiologygeneral practicesystemcommunicationhaloperidol
VIChome2019-10-10

Finding into death of Liana Pickup

32y · Female·Mixed drug toxicity (methadone, oxycodone, desmethylvenlafaxine, quetiapine, ola…

Liana Pickup, a 32-year-old woman with complex mental illness (bipolar disorder, borderline personality disorder, schizoaffective disorder), chronic back pain, and substance dependence, died from mixed drug toxicity afte…

general practicepsychiatrymedicationcommunicationmethadone
VIChome2019-10-07

Finding into death of Phillip James King

52y · Male·Mixed drug toxicity

A 52-year-old man with multiple sclerosis, chronic pain, depression and history of suicidality died from mixed drug toxicity following an intentional overdose. He was prescribed multiple opioids (fentanyl, tramadol, oxyc…

general practiceneurologymedicationcommunicationfentanyl
NSWhome2019-10-04

Inquest into the death of C D

60y · Male·burn wounds and the consequences thereof

CD, a 60-year-old man with long-standing psychiatric history (schizophrenia/schizoaffective disorder) and alcohol use disorder, set his house alight on 19 September 2017 after becoming acutely unwell with paranoid ideati…

general practicepsychiatrydiagnosticcommunicationdiazepam
NT2019-09-27

Inquest into the death of Daryl Riley

42y · Male·ischaemic heart disease due to coronary artery atherosclerosis and left ventricu…

Daryl Jabangardi Riley, a 42-year-old Aboriginal prisoner, died of ischaemic heart disease due to coronary artery atherosclerosis and left ventricular hypertrophy while playing pool in the recreation room at Alice Spring…

cardiologygeneral practicediagnosticcommunication
NSWaged care2019-09-27

Inquest into the death of Epenesa PAHIVA

87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…

Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (h…

dermatologygeneral practicediagnosticcommunicationbleach

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