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NSWmental health2011-06-23

Djordevic final

32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …

A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…

obstetricsgeneral practicecommunicationsystemclozapine
NSW2011-05-31

Coroner's Finding: Cheryl Gene Grimmer

Female·Open finding - cause and manner of death could not be determined

Cheryl Gene Grimmer disappeared from Fairy Meadow Beach in NSW on 12 January 1970, sometime after 7pm. Her remains were never found and her death remained an unsolved mystery for over 40 years. An inquest was held on 9 M…

NSWcommunity2011-05-26

Coroner's Finding: Wayne Lawler

Coronary Artery Thrombosis due to Coronary Artery Atherosclerosis

Wayne Lawler died on 30 July 2009 from Coronary Artery Thrombosis due to Coronary Artery Atherosclerosis (acute myocardial infarction) at Concord Hospital. An inquest was held in May 2011 before State Coroner Mary Jerram…

paramedicineemergency medicinesystem
NSWaged care2011-05-20

Coroner's Finding: Iris Conyngham

91y · Female·traumatic subarachnoid haemorrhage and acute and chronic subdural haematoma as a…

91-year-old admitted to high-care aged care facility (Bennelong House) on 14 October 2009 following stroke and multiple falls. Within one hour of arrival, she fell from bed and lay on the floor for approximately 45 minut…

geriatric medicineproceduralcommunication
NSWhome2011-05-16

Coroner's Finding: Ethan Corless

2y · Male·Hypoxic ischaemic encephalopathy due to cardiac arrests following drowning in a …

Ethan Corless, aged 2 years, drowned in a private swimming pool at his home on 6 July 2010 and died four days later at Westmead Children's Hospital from hypoxic ischaemic encephalopathy and cardiac arrest secondary to dr…

NSW2011-05

Coroner's Finding: Michael Morris

32y · Male·hypoxic brain injury from hanging in custody

Michael Morris, 32, died from hypoxic brain injury sustained while hanging himself in Penrith Local Court cells on 4 May 2009. Arrested for heroin possession with a prior drug parole sentence, Morris was transferred to D…

systemproceduralheroin
NSW2011-04-20

Johnkudrytch&melissacookfinding2422 08&2423 08

29y · Female·gunshot wound to the abdomen

Melissa Cook (29) was shot by her estranged husband at her workplace (BP service station, Casula, NSW) on 16 December 2008. She was taken to Liverpool Hospital where she underwent emergency surgery and blood transfusions…

emergency medicinesurgery
NSW2011-04-05

Findingweekes,graemejohn1146 09

Unknown·Murdered by infliction of head and chest injuries by person or persons unknown

This is an inquest into the disappearance and presumed murder of Graeme John Weekes, who disappeared on the night of 12–13 June 1999 from Toormina, NSW. The Deputy State Coroner found that Weekes was murdered by inflicti…

NSW2011-04-04

Findings&recommendationsdrury baxter

34y · Male·Asphyxiation by hanging

James Llewellyn Drury, 34-year-old Aboriginal person with transgender identification, died by hanging in Metropolitan Remand Centre, Silverwater on 15–16 March 2009 while in custody awaiting trial. Despite vulnerability …

NSWcommunity2011-04-01

Coroner's Finding: Harmony Bryant

Female·Complications associated with burns received at Bonny Hills on 16 August 2003 at…

Harmony Bryant, a young woman, suffered severe burns and arm fractures in a violent attack at Bonny Hills on 16 August 2003. She was airlifted to hospital but died from burn complications on 19 September 2003. The corone…

emergency medicineintensive carecommunicationsystem
NSWhospital2011-04-01

Clarke,heidimaree1223 09 findings&recommendations

Female·massive intra-abdominal haemorrhage caused by injuries to her right common iliac…

Heidi Maree Clarke, a patient undergoing treatment for ectopic pregnancy, died on 30 April 2009 from massive intra-abdominal haemorrhage caused by injuries to her right common iliac artery and vein sustained during lapar…

gynaecologyprocedural
NSWhome2011-03-21

Lopes kristen,tekeishafindings

6y · Female·Hypoxic Ischaemic Brain Injury from submersion in a pool

Tekiesha Lopes-Kristen, aged 6, drowned after submersion in a home swimming pool at Wattle on 22 January 2009, dying from hypoxic ischaemic brain injury at Children's Hospital Westmead two days later. The coroner found t…

NSWcommunity2011-03-11

Coroner's Finding: Shayne Hamilton McMahon

20y · Male·Widespread hypoxic brain injury secondary to cardiac arrhythmia, ventricular fib…

Shayne McMahon, 20, died on 7 April 2007 from cardiac arrhythmia and hypoxic brain injury after exposure to butane from a severed LPG gas line at North Star Holiday Resort. As an unlicensed apprentice plumber/gasfitter, …

emergency medicineintensive careproceduralsystem
NSW2011-03-04

Patten 2012 05 02 11 56 38 733

Male·Multiple injuries from motor vehicle collision

David Ian Patten died on 7 January 2010 in a motor vehicle collision on Wybong Road near Yarraman Road, Wybong, NSW. He was driving a Toyota Hilux westbound when he encountered a Kenworth Prime Mover towing an oversized …

NSWhospital2011-03-04

Williammackenzie 2011 03 04 12 58 08 816

60y · Male·Multiple injuries sustained after jumping from 15th storey home unit

William MacKenzie, a 60-year-old with a five-year history of bipolar affective disorder and recent involuntary hospitalization, presented to St. Vincent's Hospital on 9 June 2008 with suicidal ideation after being found …

psychiatryemergency medicinediagnosticproceduralolanzapine
NSWcommunity2011-02-25

Finding&recommendations hong,asay1286 09

58y · Male·Drowning

A Say Hong, aged 58, died on 24 April 2009 after drowning in the Tasman Sea off North Bondi whilst rock fishing. He was washed from a rock ledge by a wave. This was an accidental death with no clinical involvement. The c…

NSW2011-02-25

Finding&recommendations ren,tong1133 09

28y · Male·Drowning

Tong Ren, a 28-year-old male, died by drowning on 25 April 2009 when washed from a rock ledge by a wave while fishing in the Tasman Sea off North Bondi, NSW. The coroner found the cause of death to be drowning in these c…

NSWcommunity2011-02-11

Findingmorcom,jai 11 2 11 anonymised

15y · Male·Grade 5 basal subarachnoid haemorrhage suffered during an altercation at Mullumb…

Jai Morcom, aged 15, died from a Grade 5 basal subarachnoid haemorrhage following an altercation at Mullumbimby High School on 28 August 2009. The fight erupted when a Year 9 student spat on a Year 11 student, escalating…

NSWhospital2011-02-03

Finding&recommendations owens,jonah3648 09

Unknown·Subgaleal Haemorrhage caused by position of forceps on baby's head together with…

Jonah Owens, a newborn, died at John Hunter Hospital Newcastle on 12 December 2008 from a subgaleal haemorrhage. The coroner found the death was directly caused by forceps delivery — specifically the position of the forc…

obstetricsprocedural
NSWhospital2010-12-22

Finding patience,iandonald 970 07

68y · Male·Complications following colon surgery on a background of cirrhosis of the liver;…

Ian Donald Patience, 68, died on 10 June 2007 from complications following colon surgery in the setting of cirrhosis. He underwent right hemicolectomy at Sydney South West Private Hospital on 31 May 2007 for colorectal c…

general surgerygastroenterologydiagnosticcommunicationmorphine
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