Coronial
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NSW2014-06-04

Inquest into the death of Gary McKell

67y · Male·complications of blunt force head injuries

Gary McKell, aged 67, died from complications of blunt force head injury sustained during a physical altercation with his neighbour. After consuming approximately six beers, Mr McKell became angered by noise from his nei…

neurosurgeryintensive carealcohol
NSW2013-10-29

Inquest into the death of Glen PUNCH

44y · Male·cardiac arrest and cerebral oedema consequent upon ingestion of Alpha-PVP (Smoki…

Glenn Punch, a 44-year-old truck driver, died from cardiac arrest and cerebral oedema following intravenous injection of Alpha-PVP (Smokin Slurry), a synthetic cathinone derivative. He purchased the drug from a retail ch…

toxicologyemergency medicinesystemcommunicationalpha-pvp
NSWcommunity2012-12-14

Raymond cho findings

Male·Hypoxic brain injury secondary to anaphylaxis caused by walnut ingestion

Raymond Cho, a secondary school student with a known walnut allergy, died of hypoxic brain injury following anaphylaxis at Royal Prince Alfred Hospital on 24 May 2011. He suffered anaphylaxis after ingesting walnuts, lik…

emergency medicineintensive caredelaysystem
NSW2012-09-27

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

Unknown·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
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
NSWmental health2011-12-13

Coroner's Finding: Samuel Dibley

23y · Male·cerebral hypoxia secondary to strangulation from hanging by belt

Samuel Dibley, aged 23, was involuntarily admitted to the Mental Health Unit on 19 May 2009 with cannabis-induced psychosis and suicidal ideation. He was placed in the Low Dependence Unit (LDU) based on risk assessment. …

psychiatryemergency medicinerisperdone
NSWhospital2011-11-11

Coroner's Finding: John Reginald Beech

64y · Male·Postoperative intra-abdominal bleeding from pancreatic artery injury and its con…

John Reginald Beech, 64, died at Sydney Adventist Hospital on 24 April 2007 from postoperative intra-abdominal hemorrhage following colonic surgery. One week earlier, he underwent high anterior resection and hernia repai…

anaesthesiacolorectal surgerydiagnosticdelaymorphine
NSWmental health2011-09-02

Ang 2011 09 21 13 31 50 906

29y · Male·acute bronchopneumonia complicated by multi-drug toxicity

Nicholas Ang, aged 29, with schizoaffective disorder, died from acute bronchopneumonia complicated by multi-drug toxicity while in a psychiatric unit. Admitted 12 August 2005, he was on clozapine, valproic acid, and clon…

psychiatrygeneral medicinemedicationcommunicationclozapine
NSWhospital2011-08-15

Coroner's Finding: Jacob Leonel Belim

8y · Male·Septic shock consequent on burst appendix with peritonitis

Jacob Belim, aged 8, presented to a GP with appendicitis on 24 March 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Li…

emergency medicinegeneral practicediagnosticcommunicationampicillin
NSW2011-07-01

Coroner's Finding: Michael Peter Magro

40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…

Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…

correctional healthgeneral practicediagnosticcommunicationmethadone
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
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
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
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
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
NSWhospital2010-07-22

Finding helanisirianni257 08 dscmitchell

Female·Hypoxic ischaemic encephalopathy following hypovolaemic shock and multi-organ fa…

Helani Sirianni, born 8 February 2008, died less than 3 days later from subgaleal haemorrhage and multi-organ failure. She was delivered by vacuum extraction after labour complicated by fetal distress. The vacuum extract…

obstetricsmidwiferydiagnosticcommunication
NSW2010-02-16

Coroner's Finding: Shannon Abby-Rose Rankin

11y · Female·Drowning following entrapment on the active main drain of the spa pool

An 11-year-old girl drowned in a spa pool at a residential apartment complex after becoming entrapped on an active main drain filter. The drain had been completely blocked during construction by cement, aggregate, and ot…

intensive careretrieval medicineproceduralsystem
NSWhospital2009-06-12

Coroner's Finding: Rebecca Murray

29y · Female·Multisystem organ failure following postpartum haemorrhage due to atonic uterus

Rebecca Murray, 29, died from multisystem organ failure following postpartum haemorrhage after an emergency caesarean section at Bathurst Base Hospital on 24–25 June 2007. The coroner found her death preventable. Key cli…

obstetricsanaesthesiasystemcommunicationoxytocin
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