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TASaged care2016-09-01

Coroner's Finding: Westcott, Barbara

84y · Female·Positional asphyxia due to head and neck entrapment between mattress and bed pol…

Barbara Westcott, aged 84, died of positional asphyxia on 31 March 2012 when her head and neck became trapped between her mattress and a bed pole at Vaucluse Gardens aged care facility in Hobart, Tasmania. The bed pole, …

geriatric medicinegeneral practicesystemdelay
TAShospital2016-08-26

Coroner's Finding: Brook, Jason Mark

45y · Male·massive pulmonary embolism due to deep vein thrombosis of the left leg

A 45-year-old man died of massive pulmonary embolism secondary to deep vein thrombosis, 15 days after a motorcycle injury in Thailand requiring surgical wound management and foot fracture immobilization. He was discharge…

orthopaedic surgerygeneral surgerymedicationcommunicationenoxaparin
TASmental health2016-08-16

Coroner's Finding: Pasinski, Alexander

59y · Male·asphyxia due to choking on food

Alexander Pasinski, age 59, died from asphyxia due to choking while an involuntary psychiatric patient in Launceston General Hospital's Northside unit. He had major depression and paranoid schizophrenia with complex psyc…

psychiatryintensive caresystemcommunicationamitriptyline
TAShospital2016-08-08

Coroner's Finding: Teressa Beswick

45y · Female·Combined effects of widely metastatic (end-stage) carcinoma of the cervix and br…

Teressa Maree Beswick, a 45-year-old woman with end-stage metastatic cervical cancer, died from the combined effects of her cancer and bronchopneumonia accelerated by a critical medication error. On 23 October 2014, she …

emergency medicinegeneral practicemedicationproceduralmorphine
TAShome2016-08-01

Coroner's Finding: Reardon, Jean May

86y · Female·Multiple organ failure following sepsis due to infected pressure ulcer of the hi…

Jean May Reardon, an 86-year-old widow living at home with limited mobility, required care from her adult children. Following an influenza illness, she developed multiple pressure ulcers within 7-10 days, particularly on…

general medicinegeriatric medicinedelaysystem
TAShome2016-08-01

Coroner's Finding: Margaret Nicol Foran

77y · Female·Asphyxia from manual strangulation and smothering

Margaret Nicol Foran, aged 77, was killed by her son while he was experiencing an acute psychotic episode at her home in Launceston, Tasmania, between 22-23 April 2012. The cause of death was asphyxia from manual strangu…

TAS2016-07-25

Coroner's Finding: Kupsch, Jessica Ann

29y · Female·Multiple severe blunt traumatic injuries to the face, neck and head

Jessica Ann Kupsch, aged 29, was murdered by her partner Matthew Tunks at the Penny Royal Hotel in Launceston on 9 August 2012 after years of severe family violence. Despite a non-contact family violence order preventing…

systemdelay
TAShome2016-07-22

Coroner's Finding: ADT

0y · Female·subdural haemorrhage, intracranial haemorrhage and oedema caused by severe shaki…

ADT was a 10-week-old infant who died from subdural haemorrhage and intracranial haemorrhage caused by severe non-accidental injury. She presented to Launceston General Hospital with fever, poor feeding, and loose stools…

neonatologypaediatricscannabis
TAShospital2016-07-18

Coroner's Finding: Henriksen, Wendy Margaret

72y · Female·probable sepsis complicating chemotherapy for non-Hodgkin's lymphoma

A 72-year-old woman died of sepsis complicating chemotherapy for non-Hodgkin's lymphoma. She presented to ED with severe abdominal pain, elevated lactate (6.1 mmol/L), and signs of shock. The surgical team failed to reco…

emergency medicinesurgerydiagnosticdelaypiperacillin/tazobactam
TAShome2016-07-14

Coroner's Finding: Bedford, Sidney

83y · Male·Acute subdural haemorrhage following a fall

Sidney Bedford, aged 83, fell on his driveway at home on 30 October 2015 and suffered a head injury while on warfarin anticoagulation therapy. He was transported to Launceston General Hospital where an initial CT scan of…

emergency medicineradiologydiagnosticwarfarin
TAShome2016-07-12

Coroner's Finding: Blackaby, Kobie

1y · Male·drowning

Kobie Ryder Blackaby, 18 months old, drowned in an unsecured inflatable backyard pool on 25 February 2014 in Hobart, Tasmania. The pool, containing 495mm of water, exceeded the 300mm threshold requiring safety fencing un…

TASmental health2016-07-09

Coroner's Finding: Slater, Timothy Guy

38y · Male·Unknown - body never located

Timothy Guy Slater, aged 38, disappeared from Fern Tree, Tasmania on 9 June 1987 while on leave from psychiatric inpatient care at Royal Hobart Hospital where he was being treated for depression. He had a history of prev…

psychiatry
TAScommunity2016-06-30

Coroner's Finding: Ball, Jeremy Dacre

46y · Male·Multiple blunt traumatic injuries sustained in motor vehicle crash; manner deter…

Jeremy Ball, aged 46, Deputy Mayor of Launceston, died on 15 September 2014 when he deliberately steered his vehicle into the path of a loaded truck on the Bass Highway, sustaining fatal blunt traumatic injuries. The cor…

general practicepsychiatrydelay
TAScommunity2016-06-30

Coroner's Finding: James, Damien Aron

33y · Male·Multiple traumatic injuries

On 7 February 2014, Damien Aron James, aged 33, died following a single motor vehicle crash on the Midland Highway near Powranna, Tasmania. An experienced crash investigator concluded Mr James fell asleep while driving. …

TAS2016-06-29

Coroner's Finding: McDougall, Kirsten

34y · Female·Aspiration pneumonia due to traumatic brain injury

Kirsten McDougall, aged 34, died on 20 July 2015 from aspiration pneumonia, 16 months after suffering severe traumatic brain injury in a single-vehicle motor crash on 7 February 2014 on the Midland Highway in Tasmania. T…

TAScommunity2016-06-27

Coroner's Finding: Grey, Andrew Amos

45y · Male·drowning

Andrew Amos Grey, a 45-year-old experienced builder and competent boater, drowned on 29 December 2014 at Burns Bay, St Helens, Tasmania, when his recreational boat capsized in rough seas. Although Mr Grey was skilled and…

TAShospital2016-06-27

Coroner's Finding: Mr P

64y · Male·Small bowel infarction due to a volvulus owing to adhesions in the small intesti…

Mr P, aged 64, presented to Royal Hobart Hospital's Emergency Department in October 2012 with severe central abdominal pain. The ED consultant diagnosed bowel obstruction but failed to consider critical complications suc…

emergency medicinegeneral surgerydiagnosticdelay
TAScommunity2016-06-24

Coroner's Finding: Moylan, Mark David

42y · Male·drowning

Mark David Moylan, aged 42, drowned in the Tamar River near Gravelly Beach, Tasmania, on 25 January 2014. He had a long history of substance abuse and mental health problems, including depression and bipolar affective di…

diazepam
TAScommunity2016-06-20

Coroner's Finding: Gordon, Mark Alexander

51y · Male·Pericardial tamponade complicating Type I aortic dissection in the setting of lo…

Mark Gordon, 51, presented to Royal Hobart Hospital Emergency Department on 20 March 2015 with sudden onset chest pain. Initial assessment suspected acute coronary syndrome with elevated troponin. Over 36 hours he experi…

emergency medicinegeneral medicinediagnosticdelay
TAScommunity2016-05-31

Coroner's Finding: Jackson, Christopher George

17y · Male·Drowning

This 2016 finding investigates the 1958 disappearance of 17-year-old Christopher George Jackson from Hobart, Tasmania. On 18 December 1958, Christopher was aboard a boat on the Derwent River with friends celebrating the …

alcohol
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