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NSWcommunity2012-11-14

Inquest into the death of Roberto Laudisio CURTI

21y · Male·undetermined causes, in the course of being restrained by members of the NSW Pol…

Roberto Laudisio Curti, a 21-year-old Brazilian, died on 18 March 2012 during police restraint in Sydney after consuming LSD which induced a psychotic state. After a convenience store incident was misclassified as an arm…

psychiatrytoxicologycommunicationsystemLSD
NSW2012-11-13

Daniel andrews findings

Unknown·Electrocution from overhead wiring system on the roof of a train

Daniel Grant Andrews died on 26 February 2011 after being electrocuted by overhead wiring while on the roof of a train. He was brought to Hawkesbury Hospital NSW where he died from injuries sustained in the electrocution…

NSWhospital2012-11-01

Michelle Mcilquham Findings

28y · Female·acute streptococcus pneumonia meningitis with left-sided otitis media as anteced…

Michelle McIlquham, 28 years old, died from undiagnosed acute bacterial meningitis (streptococcus pneumonia) that developed from a middle ear infection. She presented to Bankstown Hospital Emergency Department with a fir…

emergency medicinediagnosticcommunication
NSW2012-10-04

Inquest into the death of Marcus WILSON

19y · Male·Complications arising from hyperthermia, including total organ failure, rhabdomy…

Marcus Wilson, a 19-year-old roofing insulator, died from hyperthermia-induced organ failure, rhabdomyolysis and coagulopathy after working in a roof space during extreme heat (40°C+) without adequate hydration. He consu…

emergency medicineoccupational and environmental healthsystemcommunication
NSW2012-09-27

Inquest into the deaths of James UNICOMBE, Michael POOLE, Grace YATES

Three deaths with different primary causes: James Unicomb - acute toxicity due t…

Combined inquest into three deaths at Psyche South Clinic involving treatment failures: James Unicomb (22, 2005) from multi-drug overdose after naltrexone implant; Michael Poole (48, 2008) from ruptured aneurysm post-Rap…

addiction medicinegeneral practicediagnosticmedicationnaltrexone
NSWcommunity2012-09-05

Inquest into the death of Lynda Vanessa CLIFFORD

29y · Female·respiratory depression as a result of the interaction of prescribed medications

A 29-year-old woman with mental illness and substance use was admitted to hospital with psychosis and suicidality. She was discharged on six CNS-depressant medications including three antipsychotics, an antidepressant, a…

psychiatrygeneral practicecommunicationsystemclozapine
NSWhome2012-06-28

Roisin Fraser Finding

0y · Female·Hypoxic episode, probably caused by cord entanglement during delivery

A neonate (Roisin) died within 90 minutes of unattended home birth on 27 March 2009. The mother, Janet Fraser, is an advocate for natural birth and rejected all antenatal care despite risk factors including previous caes…

obstetricsmidwiferydiagnosticprocedural
NSW2012-06-20

Kolomaka inquest findings

Male·Traumatic injuries to the left chest wall, left lung and heart due to high press…

Setaleki Kolomaka died on 22 May 2008 at Port Kembla steelworks when a high-pressure water jetting lance struck him fatally in the chest and heart. The inquest found multiple systemic failures: the lance lacked handles o…

system
NSW2012-06-15

Johnson graham inquest redacted findings

21y · Male·Blunt force head injuries sustained in motor vehicle crash during police pursuit

Graham Johnson, age 21, died on 18 January 2009 following a motor vehicle crash sustained as a passenger in a Suzuki Swift driven by Benjamen Pappin during a police high-speed pursuit on the New England Highway near Deep…

communicationsystem
NSWhospital2012-06-14

Beverly ann murphy finding & recommendations 0701 08

70y · Female·Hypoxic/Ischaemic Encephalopathy consequent upon Cardiorespiratory Arrest and Co…

Beverly Ann Murphy, 70, underwent hysterectomy for endometrial carcinoma on 2 April 2008 at Royal Hospital for Women. The complex surgery was complicated by iatrogenic small bowel perforations. Post-operatively, wound de…

gynaecologyoncologydiagnosticcommunication
NSW2012-05-31

Findings & recommendations pulver 2012 06 15 13 04 18 491

39y · Male·Multiple injuries from crushing incident between front-end loader and fuel truck…

David Pulver, aged 39, died on 1 July 2010 when crushed between a front-end loader and his fuel truck at a construction site near Tarcutta, NSW. The loader operator, Mr Wickey, was reversing the machine while Pulver stoo…

communicationsystem
NSW2012-05-17

Hainaut okeefe

Unknown·Multiple injuries sustained in aircraft crash resulting from gross negligence an…

Pilot Michael James O'Keefe crashed his ultralight aircraft at Tatham, NSW on 7 May 2010, killing himself and passenger Josef Pierre Hainaut. The coroner found O'Keefe was performing unauthorized aerobatic maneuvers (inc…

system
NSW2012-05-15

Grainger ,helen finding 1767 08 2012 05 31 14 40 06 300

29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…

Helen Grainger, 29, with polycystic kidney disease and asthma, underwent pregnancy termination at Lambton Road Day Surgery in April 2007. She developed anaphylaxis post-procedure (likely cephalosporin-triggered) with car…

general practiceobstetricsproceduralsystemcephalosporin
NSWaged care2012-05-11

Inquest into the deaths of Shaneen BATTS, Ilona TAKACS, Dorothy HUDSON, Ian BIRKS, Donald MacKELLAR and Mohammed RAMZAN

Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …

This inquest examined six sudden deaths of residents at 300 Hostel, Marrickville, between June 2009 and August 2010. All residents had schizophrenia on multiple antipsychotic medications and severe, untreated physical co…

psychiatrygeneral practicediagnosticmedicationolanzapine
NSW2012-05-07

Inquest into the death of Momtaz KABBOUT

46y · Male·multiple gunshot wounds inflicted by person or persons unknown

Momtaz Kabbout, a 46-year-old driving instructor, was found dead in Shortland Brush Reserve, Lansdowne on 3 July 2012 with multiple gunshot wounds. Forensic autopsy revealed he had been shot five times with all bullets f…

forensic medicinepathology
NSW2012-04-24

Shane o donoghue and nicholas costin findings of deputy state coroner brydon 24 04 2012

Male·Multiple injuries sustained from aircraft in-flight break-up and ground impact

Two men—passenger Shane O'Donoghue (50) and pilot Nicholas Costin—died on 5 October 2006 when their Strikemaster jet broke up in flight near Bathurst, NSW during an adventure flight. The aircraft broke apart at low altit…

diagnosticprocedural
NSW2012-04-20

Parsons final findings doc

Male·Cardiac arrhythmia secondary to cardiac sensitisation from acute exposure to Bos…

Michael Parsons, a qualified shipwright employed by Seawind Catamarans for 7 years, died on 25 August 2008 after acute inhalation of Bostik 9913 solvent vapours while cleaning the interior of a catamaran hull at Bellambi…

toxicologyparamedicinesystembostik 9913
NSWmental health2012-04-17

Coroner's Finding: DB

28y · Male·ligature strangulation

DB, a 28-year-old with first episode psychosis, was admitted to Nepean Hospital on 31 March 2009 after self-harming. He was appropriately diagnosed and treated with olanzapine under the Mental Health Act. Two independent…

psychiatrycommunicationsystemolanzapine
NSW2012-03-28

Coroner's Finding: Marc Peter Farrell Kimber

Male·Complications of Prader-Willi Syndrome (including morbid obesity)

Marc Peter Farrell Kimber, a resident of a disability care facility, died on 12 March 2010 from complications of Prader-Willi Syndrome including morbid obesity. The coroner found no indication of medical negligence or cl…

disability medicine
NSW2012-02-24

Coroner's Finding: Tevita (David) Taufahema

18y · Male·gunshot wound to the head

David Taufahema, 18 years old, was fatally shot in the head by Senior Constable Simon Ross during a police response to an armed robbery at the Canley Heights Hotel, Canley Heights, NSW on 1 September 2009. Taufahema and …

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