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NSWhospital2014-07-14

Inquest into the death of John McFerrier

51y · Male·Sepsis with multi-organ failure; pneumonia (multi-drug resistant Staphylococcus)…

John McFerrier, a 51-year-old man in immigration detention, died from sepsis with multi-organ failure and multi-drug resistant pneumonia, complicated by morbid obesity. He was admitted to Liverpool Hospital ICU with brea…

intensive careinfectious diseasesantidepressants
NSWhospital2014-07-11

Inquest into the death of Toni Ann PEADON

52y · Female·laceration of the superior vena cava and right atrium during defibrillator lead …

A 52-year-old woman with a history of syncope and mitral valve prolapse, who had an implanted defibrillator, underwent a percutaneous laser lead extraction procedure at Westmead Hospital to remove and replace defective l…

cardiologycardiothoracic surgerysystemdelay
NSWcommunity2014-06-27

Inquest into the deaths of Christopher SALIB, Nathan ATTARD and Shamsad AKHTAR

Christopher Salib: ischaemic heart disease with multiple prescription drug toxic…

This landmark inquest examined three deaths involving prescription drug toxicity: Christopher Salib (24, ischaemic heart disease with drug toxicity), Nathan Attard (34, multi-drug toxicity), and Shamsad Akhtar (35, multi…

general practiceemergency medicinediagnosticmedicationalprazolam
NSWmental health2014-06-18

Inquest into the death of Mark Richard GLEESON

39y · Male·respiratory failure as a result of the interaction of prescribed medication and …

Mark Richard Gleeson, 39, died from respiratory failure caused by the combined effect of prescribed antipsychotic/anxiolytic medications (olanzapine, quetiapine, clonazepam) and alcohol consumed within hours of discharge…

psychiatryolanzapine
NSW2014-06-16

Inquest into the death of Tracylee BRANNIGAN

42y · Female·Heroin toxicity, self-administered

Tracylee Brannigan, a 42-year-old woman in custody at Dillwynia Correctional Centre, died from heroin toxicity on 24-25 February 2013. The coroner found she self-administered a potentially fatal dose of heroin after bein…

forensic medicinetoxicologyheroin
NSWhome2014-06-06

Inquest into the death of Leoni Chandrika FELIX

32y · Female·multiple sharp force wounds and blunt force injuries of the head inflicted by Ma…

Leoni Felix, a 32-year-old woman, was killed by her ex-husband through multiple stab wounds and blunt force injuries. This case, while primarily a homicide investigation rather than a medical error case, highlights the t…

psychiatryforensic medicine
NSW2014-06-06

Inquest into the death of Mandaswamy SHANKARANARAYANA

40y · Male·Suicide by hanging while on remand in custody

A 40-year-old man remanded in custody on homicide charges died by hanging in his prison cell 7 months after arrest. He had been assessed as at risk of self-harm initially and placed under 'green card' (two-person cell) s…

psychiatrypsychologysystemcommunication
NSW2014-06-06

Inquest into the disappearance and suspected death of Jessica Beth SMALL

15y · Female·Abduction and murder by person or persons unknown

Jessica Small, 15, went missing in suspicious circumstances in October 1997 while hitchhiking in Bathurst, NSW. A witness (Vanessa Conlan) credibly reported abduction by an unknown man in a white Holden Commodore. The co…

systemcommunication
NSW2014-06-04

Inquest into the death of Gary McKell

67y · Male·complications of blunt force head injuries

Gary McKell, aged 67, died from complications of blunt force head injury sustained during a physical altercation with his neighbour. After consuming approximately six beers, Mr McKell became angered by noise from his nei…

neurosurgeryintensive carealcohol
NSWaged care2014-05-23

Inquest into the death of Beryl Joyce WATSON

70y · Female·Aspiration pneumonia, associated with Huntington's disease

Beryl Watson, a severely disabled 70-year-old with advanced Huntington's disease and dementia, died of aspiration pneumonia following a three-week respite stay at a BUPA aged care facility. Critical failures included: om…

geriatric medicinegeneral practicemedicationcommunicationclonazepam
NSW2014-05-21

Inquest into the death of GB

38y · Male·asphyxiation due to hanging

A 38-year-old remand prisoner with a long history of drug dependency died by asphyxiation from hanging in his cell at a metropolitan remand centre in September 2011. He had been assessed multiple times by the Risk Interv…

psychiatryaddiction medicineproceduralmethamphetamine
NSWhome2014-05-09

Inquest into the death of Adam HAYWARD

33y · Male·multi-drug toxicity as a result of misadventure

Adam Hayward, a 33-year-old with borderline personality disorder, poly-substance abuse, and a complex psychiatric history including recurrent suicidal ideation and overdoses, died from multi-drug toxicity in October 2009…

psychiatryemergency medicinequetiapine
NSWhospital2014-05-09

Inquest into the death of Tama GALIERE

0y · Unknown·focal ventricular myocarditis and myonecrosis resulting from migration of a Peri…

A 10-month-old boy died from myocarditis and myonecrosis caused by migration of a PICC line into his right ventricle. The line was inserted appropriately under general anaesthetic for IV antibiotics treating periorbital …

paediatricsanaesthesiaproceduralcommunication
NSWhospital2014-05-09

Inquest into the death of Brendan BURNS

24y · Male·acute hydrocephalus due to undiagnosed colloid cyst of the third ventricle of th…

Brendan Burns, 24, died from acute hydrocephalus caused by an undiagnosed colloid cyst of the third ventricle. He presented with progressive severe occipital headaches, dizziness, blurred vision, nausea and vomiting over…

emergency medicineneurosurgerydiagnosticcommunicationmorphine
NSWmental health2014-05-08

Inquest into the death of Hugh David LISLE

24y · Male·cardio-respiratory arrest due to multi-drug toxicity

Hugh Lisle, a 24-year-old man with severe chronic arthritis, depression, polysubstance addiction and gambling disorder, died in a private psychiatric facility after admission for substance withdrawal management. Death re…

psychiatryemergency medicinecommunicationsystemdiazepam
NSWaged care2014-05-02

Inquest into the death of Leslie ARMSTRONG

84y · Male·Multiple blunt force injuries sustained from fall from balcony

An 84-year-old man died from blunt force injuries sustained when he fell from a second-floor balcony at an aged care facility. Investigation revealed the balcony railings had failed due to wood rot and structural deterio…

systemdelayvenlafaxine
NSWcommunity2014-05-01

Inquest into the death of Elijah HOLCOMBE

24y · Male·Gunshot wound to the chest inflicted by Senior Constable Rich of New South Wales…

Elijah Holcombe, aged 24, died from a gunshot wound inflicted by Senior Constable Rich during a police encounter in Armidale. Elijah had mental health issues and was being assessed at hospital when he left voluntarily be…

psychiatryemergency medicinecommunicationsystem
NSWhome2014-04-24

Inquest into the death of SS

50y · Female·Cyanide toxicity

A 50-year-old woman with complex mental illness including depression, anxiety, and borderline personality disorder died from cyanide toxicity after ingesting potassium cyanide obtained from Sigma-Aldrich. She made four a…

psychiatrypsychologysystempotassium cyanide
NSWcommunity2014-04-07

Inquest into the death of Jordan Leigh SARGENT

21y · Female·hypoxic brain injury due to choking on food, with Bardet-Biedl Syndrome as a con…

Jordan Sargent, a 21-year-old with Bardet-Biedl Syndrome causing intellectual disability and developmental delays, died from hypoxic brain injury after choking on a Jaffa lolly while being driven in a minibus by a disabi…

emergency medicinepathologycommunicationsystem
NSWcommunity2014-04-07

Raj final redacted version 07 04 14

21y · Male·multiple injuries from head-on motorcycle collision sustained during high-speed …

Hamish Raj, a 21-year-old TAFE student, died from injuries sustained in a head-on motorcycle collision on Rocky Point Road, Kogarah during a police pursuit on 10 December 2011. The pursuit was initiated when he failed to…

alcohol
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