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NSW2010-12-21

Coroner's Finding: Charles Athanasias Avouris

30y · Unknown·gunshot wound to the head inflicted by a person or persons unknown

Charles Avouris, aged 30, was found dead at his home (Railway House, Mumbil) on 2 July 1996, having last been seen on 1 July 1996. A forensic pathology autopsy confirmed death by gunshot wound to the head. The coroner's …

NSWhospital2010-12-21

Coroner's Finding: Joan Dennison

78y · Female·sepsis and aspiration with metabolic dysfunction as a result of mechanical small…

Joan Dennison, aged 78, was discharged from Shellharbour Hospital emergency department on 16 November 2007 with a misdiagnosis of constipation, despite clinical and imaging features diagnostic of small bowel obstruction …

emergency medicinegeneral surgerydiagnosticcommunicationmetoclopramide
NSWhome2010-12-15

Al mayahiasaad1995 09

42y · Male·Accidental carbon monoxide poisoning after exposure to fumes from barbecue briqu…

A 42-year-old man died from accidental carbon monoxide poisoning after a small barbecue with burning charcoal briquettes was brought indoors into a sealed apartment. The barbecue was lit on the balcony to cook food, then…

toxicology
NSW2010-12-14

Coroner's Finding: Craig Anthony Behr

Male·Head injury caused by Michael Allan Heatley beating and kicking Craig Anthony Be…

Craig Anthony Behr, an inmate at Long Bay Correctional Complex, was killed on 27 March 2004 when placed in a cell with another inmate, Michael Heatley, despite explicit warnings three days prior from a forensic psycholog…

systemcommunication
NSW2010-12-14

Maryannroberts281 05 finding14december2010

73y · Female·Bacterial endocarditis organism arising from a staphylococcal infection that ent…

Mary Roberts, aged 73, received a 5-year custodial sentence in September 2004. She had complex medical needs: dementia from previous strokes, diabetes requiring insulin monitoring, and Warfarin use. Justice Health provid…

correctional healthgeriatric medicinediagnosticcommunicationwarfarin
NSWhome2010-12-13

Coroner's Finding: Paul Justyn Brauer

64y · Male·Large pulmonary embolus (origin undetermined)

Paul Brauer, 64, died of pulmonary embolus at Leeton District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. The coroner ident…

psychiatrygeneral medicinediagnosticmedicationlactulose
NSW2010-12-08

Coroner's Finding: Timothy Jon Haynes

Traumatic asphyxia as a result of being buried by soil and a steel beam followin…

Timothy Jon Haynes died on 14 May 2009 in East Maitland, NSW, when a trench wall collapsed during excavation work, causing him to be buried by soil and a steel beam. He died from traumatic asphyxia. The coroner found the…

NSW2010-12-03

Inquest into the death of Dianne BRIMBLE recommendations

Female·death occurring on cruise ship; circumstances involved drug administration

Dianne Brimble died on a cruise ship in 2002 in circumstances involving drug administration. The inquest, resumed in 2010 for recommendations, identified systemic failures in cruise ship regulation, crime investigation j…

systemdelay
NSW2010-12-03

Nixon daneekapriscilla findings

25y · Female·Undetermined. Coroner stated 'the evidence adduced does not enable me to determi…

Daneeka Priscilla Nixon, 25, was found deceased in a waterhole on a rural property near Lismore NSW on 20 April 2006, four days after she was last seen alive at an Easter weekend party. Witnesses described her as progres…

cannabis
NSW2010-11-30

Inquest into the death of Diane BRIMBLE findings

42y · Female·gamma hydroxybutyrate (GHB) toxicity; cardiorespiratory depression

A 42-year-old woman holidaying on a cruise ship died from gamma hydroxybutyrate (GHB) toxicity. She was unknowingly given GHB by male passengers who subsequently engaged in sexual abuse while she was incapacitated. The s…

emergency medicineforensic medicinecommunicationdelaygamma hydroxybutyrate
NSWhospital2010-11-05

Chan findingsfinal26oct2010

77y · Female·Intracranial haemorrhage suffered during the course of neurosurgery

Oi Fong Chan, a 77-year-old woman, underwent endoscopic trans-nasal pituitary surgery at Concord Hospital on 8 December 2006 to remove a benign pituitary adenoma. During the operation, the surgical team inadvertently enc…

anaesthesiaENT surgery
NSWcommunity2010-10-26

Inquest into the death of AB (429/09)

Female·Exsanguination following self-infliction of a wound with the intention of taking…

A woman with a long-standing history of mental health issues and previous suicide attempts (May 2008, September 2007, April 2008) died on 13 February 2009 from exsanguination due to a self-inflicted wound in bushland nea…

NSWcommunity2010-10-15

Coroner's Finding: Charmaine Margaret Dragun

29y · Female·Effects of multiple injuries sustained when she projected herself from the top o…

Charmaine Dragun, a 29-year-old newsreader, died by suicide at The Gap on 2 November 2007. She was diagnosed with depression and treated with escalating doses of antidepressants (Efexor, then Lexapro) by multiple health …

general practicepsychiatrydiagnosticmedicationsertraline
NSWhome2010-10-15

Coroner's Finding: Jayden Matthew Lynch

3y · Male·asphyxia secondary to epilepsy

Jayden Lynch, aged 3, died on 15 December 2008 while attending family day care in Yamba, NSW. He had epilepsy managed by a paediatrician with medications (Tegratol, Trileptac) and emergency rectal diazepam. On the day of…

paediatricssystemcommunicationtegratol
NSWhome2010-09-08

Coroner's Finding: Michael Vanquelef Capel

43y · Male·Multiple gunshot wounds received during a police operation

Michael Capel, 43, suffered from schizophrenia managed with monthly antipsychotic injections from his GP. In October 2008, he missed his injection scheduled for 5 September. His mother noticed behavioural changes and enc…

psychiatrygeneral practicesystemcommunicationhaloperidol
NSW2010-09-03

Speering monica trent findings

40y · Male·Self-inflicted gunshot wound to the head

Trent Speering, a 40-year-old NSW paramedic, shot and killed his mother Monica, then shot himself on 11 June 2008. The coroner found that Trent suffered untreated paranoid personality disorder and depression. Despite mul…

psychiatrypsychologydiagnosticcommunication
NSWhospital2010-09-03

Woodcock 2011 06 14 12 49 10 862

Male·Myocardial failure resulting from excessive pulmonary blood flow and consequenti…

One-month-old Liam Woodcock, born extremely prematurely at 27.5 weeks gestation weighing approximately 1 kilogram, died from myocardial failure secondary to excessive pulmonary blood flow in the context of severe congeni…

neonatologyintensive caremedicationproceduralpropofol
NSWhospital2010-09-02

Coxell 2011 06 14 12 32 04 475

61y · Male·cardiac tamponade caused by aortic dissection due to hypertension

Harry Coxell, a 61-year-old man with hypertension, presented to Blacktown Hospital with severe sudden-onset chest pain on 31 October 2006. The Emergency Department doctor, Dr H., assessed him as intermediate risk for isc…

emergency medicinecardiologydiagnosticproceduralglyceryl trinitrate
NSWhome2010-08-26

Coroner's Finding: Kate Therese Bugmy

26y · Female·Streptococcal Sepsis resulting from Skin Ulceration and complications of Cerebra…

Kate Therese Bugmy, a 26-year-old woman with cerebral palsy, epilepsy, and intellectual disability, died on 28 June 2007 of Streptococcal sepsis from infected pressure ulcers. She was cared for at home by her mother Daph…

general medicineemergency medicinesystemcommunication
NSWhome2010-08-25

Findingandrecommendations kovacevicjelica1919 07

unascertained natural causes

Jelica Kovacevic died of unascertained natural causes while living alone in her home unit in Newtown, NSW, sometime between 22 January 2007 and 18 October 2007. The extended interval between possible death dates reflects…

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