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ACThospital2018-11-29

AN INQUEST INTO THE DEATH OFSIAUTO ELIUTA TUNUMAFONO

43y · Female·cardiac arrhythmia (unascertained), probably fatal cardiac dysrhythmia

A 43-year-old woman collapsed at home and was found in cardiac arrest after 20-25 minutes. Ambulance arrived and recognised ventricular fibrillation but failed to defibrillate for approximately 20 minutes, despite protoc…

emergency medicinecardiologyproceduralsystem
ACThospital2018-11-26

AN INQUEST INTO THE DEATH OFADRIAN CHARLES WILFRED VAN DIE

50y · Male·Multi-organ failure caused by low flow ischaemia of coeliac artery and superior …

Adrian Van Die, a 50-year-old with severe ischaemic cardiomyopathy, underwent coronary artery bypass grafting with intra-aortic balloon pump (IABP) support. The first IABP ruptured intraoperatively and was replaced. The …

cardiothoracic surgeryintensive caresystem
ACT2018-11-01

AN INQUIRY INTO THE FIRE AT THE SYDNEY BUILDING

Fire caused by unattended cooking wok on gas stove with ignited cooking oil

A fire occurred at Sydney Building, Canberra City on 17 February 2014 in the kitchen of Japanese restaurant Izakaya Coo 2 G 4 U, caused by an unattended cooking wok on a gas stove that ignited cooking oil. A staff member…

systemdelay
ACT2018-11-01

Inquiry into a fire at the premises of Energy Services Invironmental, 60 Dacre Street, Mitchell, ACT, on 15 September 2011

Cause and origin unascertained due to ferocity of explosion and fire

A fire and explosion occurred on 15 September 2011 at Energy Services Environmental's facility in Mitchell, ACT, which processed contaminated electrical oil containing polychlorinated biphenyls. Despite comprehensive inv…

ACThome2018-09-25

Inquiry Into A Residential House Fire In Bonner And Inquests Into Deaths Arising From The Fire Interim Findings Anne Muhoro, Ezvin Mugera And Furaha Muhoro

Anne Wachera Muhoro: effects of fire (inhalation of products of combustion and b…

A residential house fire at 6 Peter Coppin Street, Bonner, ACT on 19 February 2018 killed Anne Wachera Muhoro (44), Ezvin Munene Mugera (8), and Furaha Murathime Muhoro (5). The fire had multiple seats of ignition and wa…

ACTcommunity2018-08-14

AN INQUEST INTO THE DEATH OFTIMOTHY ALLEN SMITH-BROWN

Male·Multiple injuries including subarachnoid haemorrhage and left pleural effusion s…

Timothy Smith-Brown died from multiple injuries sustained in a motor vehicle collision after a police pursuit on 4 September 2015 in Canberra, ACT. The pursuit lasted approximately 3 minutes and involved speeds exceeding…

communicationsystemamphetamine
ACThospital2018-06-28

AN INQUEST INTO THE DEATH OFJOSEPH YATRAS

52y · Male·Left chest cavity and abdominal cavity haemorrhage due to multiple rib fractures…

A 52-year-old man died from massive internal bleeding (left chest and abdominal cavity haemorrhage) following a motorcycle accident with multiple rib fractures and splenic laceration. He initially appeared to recover wit…

trauma surgeryintensive carediagnosticdelaycannabis
ACT2018-06-28

AN INQUEST INTO THE DEATH OFCONSTANCE CAROLLE HARRISON

65y · Female·Severe crush injury of chest due to involvement in a motor vehicle accident

Constance Harrison, a 65-year-old primary school teacher, died from severe crush injuries sustained when struck by a school bus at a pedestrian crossing in Canberra. She was lawfully crossing with the pedestrian signal s…

ACThome2018-06-25

INQUEST INTO THE DEATH OF SUELLEN EDITH DAVIS

57y · Female·Positional asphyxia caused by the combined effect of consumption of several opia…

57-year-old woman with chronic pain died from positional asphyxia caused by consumption of multiple sedative medications. She was prescribed opioids (Fentanyl, Oxycodone) and Pregabalin, but also obtained Dolased and Pro…

general practicepain medicinecommunicationsystemoxycodone
ACThospital2018-05-04

AN INQUEST INTO THE DEATH OFTAHADESSE (TAD) KAHSAI

61y · Male·exposure and dehydration, preceded by alcohol withdrawal and chronic alcoholism

A 61-year-old man with chronic alcoholism was admitted to hospital for alcohol withdrawal management. He became confused and paranoid on the ward, received appropriate medication, but left hospital unobserved approximate…

emergency medicinegeneral medicinesystemcommunicationoxazepam
ACThospital2018-04-26

AN INQUEST INTO THE DEATH OFJOHN BELL

71y · Male·cardiac arrest due to hyperkalemia due to acute on chronic renal failure, with r…

John Bell, a 71-year-old man with history of bowel cancer, ischaemic heart disease, and chronic renal failure, underwent elective ileostomy reversal surgery. He died from cardiac arrest due to hyperkalemia and metabolic …

surgerynephrologydiagnosticsystem
ACT2018-04-11

AN INQUEST INTO THE DEATH OF STEVEN CLAUDE FREEMAN

25y · Male·Aspiration pneumonia secondary to methadone toxicity

Steven Claude Freeman, a 25-year-old Aboriginal man, died of aspiration pneumonia secondary to methadone toxicity on 27 May 2016, while incarcerated at the Alexander Maconochie Centre in the ACT. He was assessed as opioi…

addiction medicinegeneral practicediagnosticsystemmethadone
ACThome2018-02-28

AN INQUEST INTO THE DEATH OF TARA MAREE COSTIGAN

Female·Incised wounds to the neck and chest intentionally inflicted by Marcus Rappell, …

Tara Maree Costigan died on 28 February 2015 from incised wounds to her neck and chest deliberately inflicted by her ex-partner Marcus Rappell at her home in Calwell, ACT. The perpetrator was subsequently convicted and s…

ACTaged care2018-02-28

AN INQUEST INTO THE DEATH OFEDWARD ROBERT DAVIS

88y · Male·left frontal lobe haemorrhage due to a fall

Mr Edward Davis, an 88-year-old man with epilepsy, stroke, dementia and on anticoagulation therapy, fell onto a Stand-Up Lifter positioned directly in front of him while waiting for a second staff member to operate it. H…

geriatric medicineemergency medicinesystemproceduralblood thinning medications
ACTcommunity2018-02-27

AN INQUEST INTO THE DEATH OFELFRIEDE ADELE TREMETHICK

85y · Female·acute exacerbation of congestive heart failure, following injuries suffered in a…

Ms Tremethick, an 85-year-old with congestive heart failure, fell at home and suffered a lacerated forearm. Paramedics attended and initially administered methoxyflurane for pain relief. She developed fulminant pulmonary…

emergency medicineparamedicineproceduralcommunicationmethoxyflurane
ACThospital2018-01-30

AN INQUEST INTO THE DEATH OF ROBERT DOUGLAS

67y · Male·respiratory failure with antecedent causes including chronic emphysematic lung d…

67-year-old male with 40-year smoking history presented with chest symptoms in 2012. CT scan revealed a left upper lobe mass. Core biopsy was incorrectly reported as adenocarcinoma by the pathologist, despite clinical un…

respiratory medicinepathologydiagnosticsystemenoxaparin
ACT2017-12-22

AN INQUEST INTO THE DEATH OFANDREW NOLAN CHRISTIE

37y · Male·asphyxia due to oxygen deprivation secondary to inhalation of helium

Andrew Nolan Christie, a 37-year-old former soldier with PTSD and back pain, died by suicide using helium inhalation on 16 August 2017. Key clinical lessons: (1) Military veterans with untreated PTSD and relationship bre…

ACT2017-12-07

AN INQUEST INTO THE DEATH OF JACOB JAMES KELLY

24y · Male·Multiple injuries due to motor vehicle collision with retaining wall

Jacob Kelly, a 24-year-old man, died by suicide when he intentionally drove a vehicle at high speed into a retaining wall at the intersection of Mount Ainslie Drive and Fairbairn Avenue, Campbell. He had a blood alcohol …

ACThome2017-09-11

AN INQUEST INTO THE DEATH OF LESLEY MAREE SMITH

47y · Female·Sudden Unexpected Death in Alcohol Misuse (SUDAM)

Lesley Maree Smith, 47, died at home on 9 May 2013 from Sudden Unexpected Death in Alcohol Misuse (SUDAM). She had chronic alcohol misuse (2 bottles nightly) and was prescribed diazepam by her GP, Dr H., starting April 2…

general practicepathologydiagnosticcommunicationdiazepam
ACTcommunity2017-09-01

AN INQUEST INTO THE DEATH OF TATU WILHELM MICHAEL PARZEFALL

22y · Male·multiple injuries due to motor vehicle accident

A 22-year-old provisional motorcycle licence holder died from multiple injuries sustained in a motor vehicle collision on 20 February 2017. He was riding a borrowed Harley Davidson motorcycle (1690 cc engine) and attempt…

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