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TAShospital2021-08-26

Coroner's Finding: PY

0y · Unknown·sepsis leading to multiple organ failure syndrome

A 48-day-old neonate with congenital heart defect presented to the ED with fever and vomiting on 20 September 2019. Initial triage as Category 3 was inappropriate; the child required urgent assessment. The ED intern saw …

paediatricsemergency medicinediagnosticdelayparacetamol
TAShospital2021-08-23

Coroner's Finding: Cooper, Melanie Sarah 2021 TASCD 475

51y · Female·embolic infarcts complicating infective endocarditis

Melanie Sarah Cooper, aged 51, died from embolic infarcts complicating infective endocarditis secondary to chronic intravenous opioid use. She presented with severe physical deterioration over three days including swolle…

intensive careinfectious diseasesdelaymorphine
QLD2021-08-20

Caramin, Olivier Max - Non-inquest findings

27y · Male·multiple organ failure due to or as a consequence of heat stroke

Olivier Caramin, a 27-year-old Belgian national on a working holiday visa, died from heat stroke while picking pumpkins on 31 October 2017 in Far North Queensland. He was just three days into farm work without proper acc…

occupational and environmental healthemergency medicinesystemdiagnostic
VICmental health2021-08-20

Finding into death of Marilyn

62y · Female·Unascertained

Marilyn, a 62-year-old woman with schizophrenia and intellectual disability, died at Caulfield Hospital on 27 October 2019 with an unascertained cause. She was admitted via the ED under mental health legislation with det…

psychiatrygeriatric medicinefluoxetine
VICcommunity2021-08-18

Finding into death of David Perry

35y · Male·unascertained - multifactorial: underlying ischaemic heart disease, drug intoxic…

David Perry, aged 35, died from unascertained causes during police arrest at Bellbrae on 11 January 2019. He presented to The Alfred with acute paranoia, hallucinations and agitation following synthetic cannabis use, and…

emergency medicinepsychiatrysynthetic cannabinoids
NSWcommunity2021-08-18

Inquest into the death of A F

24y · Male·multiple stab wounds to the chest that he inflicted upon himself

A 24-year-old man with diagnosed schizophrenia experienced a relapse and engaged in a dangerous spree involving vehicle theft, assault, and police pursuit. Despite psychiatric treatment with antipsychotics, he stopped me…

psychiatrygeneral practicesystemcommunicationlurasidone
VIChospital2021-08-16

Finding into death of XA

39y · Male·Complications arising from widely disseminated primary pulmonary small cell carc…

A 39-year-old male inmate died from complications of widely disseminated small cell lung cancer with hepatitis C cirrhosis. He presented with acute psychosis and catatonia in December 2018, receiving appropriate psychiat…

psychiatryoncologyolanzapine
VICcommunity2021-08-16

Finding into death of Phillip John Sealey

62y · Male·Diabetic ketoacidosis in a man with coronary atherosclerosis and cardiomegaly

Phillip Sealey, 62, presented to his local GP on 27 June 2019 with three weeks of thirst, urinary frequency, nocturia, blurred vision, dizziness and vomiting. The GP diagnosed hypertension and suspected diabetes mellitus…

general practiceemergency medicinediagnosticdelayfentanyl
VIChospital2021-08-11

Finding into death of Mariza Beretta

52y · Female·Presumed SUDEP (Sudden Unexplained Death in Epilepsy)

Mariza Beretta, a 52-year-old woman with Trisomy 21 and early-onset Alzheimer's disease, died from presumed SUDEP (Sudden Unexplained Death in Epilepsy) at Royal Melbourne Hospital. She was diagnosed with genetic general…

neurologygeriatric medicinesodium valproate
WAhome2021-08-10

Inquest into the Death of Scott William MARTIN

40y · Male·Penetrating wounds to the chest

Scott William Martin, aged 40, was fatally stabbed in his apartment in Halls Head, Western Australia in January 2017 by Damian Maxfield, who was experiencing a methamphetamine-induced psychotic episode. Maxfield had been…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
TAS2021-08-09

Coroner's Finding: Negga, Retbe Chide

50y · Male·blunt trauma of the abdomen, pelvis and legs

Retbe Chide Negga, an Ethiopian-born seasonal farm worker, died from crush injuries after his leg became trapped beneath a trailer wheel while attempting to board a moving tractor-trailer at a cherry orchard. Key clinica…

trauma surgeryemergency medicinesystemcommunicationketamine
WAhospital2021-08-06

Inquest into the Death of Alex Carl MILLS

76y · Male·Sepsis, with osteomyelitis and infective endocarditis

Alex Mills, a 76-year-old sentenced prisoner with complex medical history including atrial fibrillation, valvular heart disease, and rheumatoid arthritis, died from sepsis caused by osteomyelitis and infective endocardit…

infectious diseasescardiologydiagnosticdelayprednisolone
TAScommunity2021-08-04

Coroner's Finding: Haigh, Kevin Bruce

62y · Male·drowning

Kevin Bruce Haigh, a 62-year-old experienced commercial rock lobster fisherman, drowned after falling from his fishing vessel FV Yimbala into the sea near Maria Island on 5 July 2020. He was recovered after approximately…

emergency medicineforensic medicine
VIChome2021-08-04

Finding into death of NB

1y · Male·Global cerebral ischaemia in an infant with upper airway obstruction

NB, a 14-month-old with a tracheostomy requiring overnight nursing support in foster care, suffered a cardiac arrest on 17 December 2016 that resulted in severe hypoxic brain injury and death. The overnight nurse (Ms Jar…

respiratory medicineintensive carediagnosticcommunication
TAShome2021-07-30

Coroner's Finding: Fitz-gerald, Peter John

56y · Male·Combined effects of head injuries and aspiration from head and facial injuries, …

Peter John Fitz-gerald, aged 56, died from combined head injuries, facial injuries with aspiration, and acute alcohol intoxication following a violent assault by Anthony Colin Finnegan on 1 December 2016 at Summerhill, T…

forensic medicineemergency medicinealcohol
NSWcommunity2021-07-30

Inquest into the death of A J

36y · Male·multiple injuries consistent with a fall from a height

A 36-year-old man with severe depression, social isolation, and recent life crises (job loss, marital breakdown, reduced child contact) posted suicidal messages on social media and stood on a cliff ledge. Police negotiat…

psychiatrycorrectional healthcommunicationdelaysertraline
WAhospital2021-07-30

Inquest into the Death of Chad RILEY

39y · Male·Cardiac arrhythmia following violent exertion necessitating physical restraint i…

39-year-old Chad Riley died from cardiac arrhythmia following violent exertion during physical restraint. He presented to hospital intoxicated with methylamphetamine, exhibiting drug-induced psychosis with agitation and …

emergency medicinepsychiatrysystemmethamphetamine
TAShospital2021-07-27

Coroner's Finding: Menzies, Mervyn Roy

Male·aspiration pneumonia

Mervyn Roy Menzies, a 60+ year old man with intellectual and physical disabilities, died of aspiration pneumonia at Royal Hobart Hospital on 12 July 2020. He presented on 6 July with fever and difficulty swallowing; CT i…

emergency medicinegeneral medicine
TAShospital2021-07-26

Coroner's Finding: Sowden, James Robert

65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists

James Robert Sowden, aged 65, died by self-inflicted neck and wrist wounds on 28-29 March 2018. He had a history of depression with paranoid features (diagnosed 2003) and autoimmune thyroiditis. In the week before death,…

psychiatryemergency medicinediagnosticcommunicationquetiapine
QLD2021-07-26

Cunningham, Luke

21y · Male·Hanging

Luke Cunningham, aged 21, died by hanging in a prison cell at Arthur Gorrie Correctional Centre in Queensland in September 2018. He was on remand facing murder charges. An initial psychological assessment upon reception …

psychiatrycorrectional healthsystem

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