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WA2020-11-19

Inquest into the Death of Levi Shane Clement CONGDON

27y · Male·methylamphetamine toxicity

Levi Shane Clement Congdon, a 27-year-old male, died from methylamphetamine toxicity on 13 November 2017 at Royal Perth Hospital during a police search warrant execution. He ingested a fatal dose of methylamphetamine, re…

emergency medicinetoxicologycommunicationsystemmethamphetamine
WAcommunity2020-11-05

Inquest into the Suspected Death of Paul Clifford YORK

45y · Male·unascertained

Paul Clifford York, 45, disappeared from Petrudor Rocks National Park on 10 November 2011 and is presumed dead. He had a long history of depression, suicidal ideation, and previous suicide attempts by hanging and overdos…

psychiatrygeneral practicediagnosticsystemmirtazapine
WAcommunity2020-11-04

Inquest into the Death of Andrew John KEY

49y · Male·incised injury to the neck

Andrew Key, a 49-year-old man with bipolar affective disorder, died by suicide on 11 August 2015 after self-inflicting a neck injury while being restrained by police. Clinical lessons emerged regarding mental health asse…

psychiatryemergency medicinecommunicationsystemquetiapine
WAprison2020-11-04

Inquest into the Death of Damien PURNELL

47y · Male·organ failure following cardiorespiratory impairment in a man with arteriosclero…

Damien Matthew Purnell, a 47-year-old prisoner with a long history of polysubstance abuse and undiagnosed coronary artery disease, collapsed in his cell after smoking synthetic cannabinoids (Kronic). Despite immediate re…

emergency medicineintensive caresystemmethadone
WAcommunity2020-10-22

Inquest into the Death of Jordana KOSTOVSKI

27y · Female·Multiple injuries sustained in motor vehicle collision

A 27-year-old woman under the influence of alcohol and methylamphetamine deliberately drove her van head-on into oncoming traffic on Forrest Highway, resulting in her death. Police had attempted to intercept her for dang…

forensic medicinetoxicologyalcohol
WAhospital2020-10-19

Inquest into the Death of Renee Desiree RUYZING

21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg

A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…

orthopaedic surgeryemergency medicinediagnosticmedicationenoxaparin
WAhospital2020-10-08

Inquest into the Death of Wayne Frederick LEESE

54y · Male·Complications including hepatic encephalopathy, pneumonia and multi-organ failur…

Wayne Frederick Leese, a 54-year-old prisoner, died from complications of hepatitis C and hepatocellular carcinoma including hepatic encephalopathy, pneumonia and multi-organ failure. He collapsed at Acacia Prison on 4 M…

hepatologyemergency medicinemethadone
WA2020-10-07

Inquest into the Death of JM (Name Subject to Suppression Order)

0y · Male·dehydration complicating diarrhoea (aetiology unknown)

A 10-week-old infant in out-of-home care in a remote Western Australian community developed acute diarrhoea and fever one day after routine immunisation. Despite appropriate initial care by foster parents and timely hosp…

paediatricsemergency medicinesystemparacetamol
WAhospital2020-09-23

Inquest into the Death of PT (Name Subject to Suppression Order)

5y · Female·aspiration of vomit with microscopic early pneumonia, in a child with a history …

A five-year-old girl with cerebral palsy and epilepsy resulting from non-accidental head injuries at two months old died from aspiration of vomit with early pneumonia. Critical lessons: bruising in non-ambulant infants i…

paediatricsgeneral practicediagnosticcommunicationtopiramate
WAhospital2020-09-04

Inquest into the Death of Malakai Matiu Ward PARAONE

0y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…

Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. …

emergency medicineintensive carediagnosticcommunicationparacetamol
WAcommunity2020-08-18

Inquest into the Death of Jessica Lesley JACKSON

18y · Female·multi-organ failure due to combined effects of environmental exposure (hyperther…

Jessica Jackson, 18, died from multi-organ failure due to combined hyperthermia and dehydration while weight-cutting for an amateur Muay Thai fight. She lost approximately 9 kg in the final week through water-loading, de…

emergency medicinesports medicinediagnosticsystem
WA2020-08-18

Inquest into the Death of Hayden Paul STACEY

22y · Male·gunshot injury to the chest

Hayden Paul Stacey, 22, died from a gunshot wound to the chest inflicted by police constable Lucinda Boon during a mental health crisis incident on 27 May 2018 at Peel Health Campus, Western Australia. Stacey had called …

emergency medicineparamedicinesystemcannabis
WAhospital2020-08-13

Inquest into the Death of Susan Jessica Elsie WINDIE

22y · Female·bowel obstruction due to faecal impaction

Susan Windie, a 22-year-old with rare congenital abnormalities affecting bowel function, died from bowel obstruction due to faecal impaction complicated by abdominal compartment syndrome. She presented to Carnarvon Hospi…

gastroenterologygeneral practicecommunicationsystemfleet enema
WAmental health2020-08-06

Inquest into the Death of Stephen Michael KELL

35y · Male·acute vomit aspiration in a man with acute large intestine obstruction (severe m…

Stephen Michael Kell, a 35-year-old man with treatment-resistant schizophrenia, died at Graylands Hospital from acute vomit aspiration in the setting of acute large bowel obstruction and clozapine-induced gastrointestina…

psychiatrygastroenterologysystemdelayclozapine
WAcommunity2020-06-15

Inquest into the Death of Thorvald Anthony NIELSEN

29y · Male·multiple gunshot wounds

A 29-year-old male died from multiple gunshot wounds inflicted by police Tactical Response Group (TRG) officers during a failed arrest operation. The deceased had stolen firearms, was suspected of being armed, and had ex…

emergency medicinetrauma surgerycommunicationsystemamphetamine
WAhospital2020-06-03

Inquest into the Death of Michael Warren DYBALL

56y · Male·bronchopneumonia complicated by multiorgan failure and hypoxic ischaemic encepha…

Michael Dyball, a 56-year-old prisoner with chronic kidney disease, hepatitis C, and treated oropharyngeal squamous cell carcinoma, collapsed in his prison cell and suffered cardiopulmonary arrest on 28 April 2016. He di…

nephrologyoncologydarbepoetin alfa
WAhospital2020-05-26

Inquest into the Death of Nualla Christine REILLY

74y · Female·Multiple injuries sustained when struck by train

A 74-year-old woman with borderline personality disorder, depression, anxiety and type 2 diabetes died by suicide after absconding from Fiona Stanley Hospital Emergency Department. She had been on extended psychiatric ad…

psychiatryemergency medicinecommunicationsystemamitriptyline
WAcommunity2020-05-14

Inquest into the Suspected Death of Thomas Dominic RAE

25y · Male·immersion in water (drowning)

Thomas Dominic Rae, aged 25, disappeared while rock fishing at Shelley Beach, Western Australia on 7 July 2019 and is presumed drowned. He had a history of mental health issues (anxiety, depression, bipolar affective dis…

emergency medicinepsychiatry
WAhospital2020-04-24

Inquest into the Death of Hassan BECHARA

52y · Male·ischaemic heart disease

Hassan Bechara, a 52-year-old prisoner, died from ischaemic heart disease in July 2017. He had complex cardiac history including dilated cardiomyopathy, triple-vessel coronary disease, and previous cardiac procedures. Cl…

cardiologyemergency medicinedelaysystematorvastatin
WAhospital2020-02-20

Inquest into the Death of Eric WUMBIE

37y · Male·valvular and ischaemic heart disease

Eric Wumbie, a 37-year-old Aboriginal male prisoner, died from valvular and ischaemic heart disease on 13 April 2016 following intraoperative cardiac arrest during planned cardiothoracic surgery at Fiona Stanley Hospital…

cardiologycardiothoracic surgerysystemcommunication
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