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VICaged care2010-02-03

Finding into death of Gladys Vincent

60y · Female·Renal carcinoma

Gladys Vincent, a 60-year-old woman with intellectual disability residing in disability services, died from renal carcinoma. She had been diagnosed with kidney cancer two years prior and was under palliative care through…

palliative caregeneral practice
VICcommunity2010-01-20

Finding into death of Jennifer Gibbins

54y · Female·Sepsis due to bronchopneumonia complicating malignant spindle cell tumour of rig…

Jennifer Gibbins, a 54-year-old woman with non-verbal communication disability living in supported accommodation, presented with recurrent cough from April 2005. Initial management consisted of antibiotics prescribed by …

general practicerespiratory medicinediagnosticdelayantibiotics
NTcommunity2010-01-19

Inquest into the death of Baby Kalib (Child 7)

0y · Male·failure to thrive due to insufficient caloric intake

Kalib died from failure to thrive due to insufficient caloric intake at 7 weeks old. He was born to a mother with a documented history of severe neglect and physical abuse of multiple children over 5 years, during which …

paediatricsgeneral practicesystemcommunication
VIChospital2010-01-15

Finding into death of Josephine Cesnik

76y · Female·complications of subdural haemorrhage (operation)

Josephine Cesnik, 76, died from complications of subdural haemorrhage following head trauma on 20 January 2008. She initially concealed the injury, attributing it to a fall, and did not seek medical attention for 9 days …

emergency medicineneurosurgerydelaywarfarin
VICcommunity2010

Finding into death of Mikael Chandra Rohan

14y · Male·head injuries when struck by a train

Mikael Rohan, a 14-year-old with a history of separation anxiety, attachment disorder, and sleep disturbance, died after stepping in front of a train on 16 November 2010. He had recently been distressed about a reported …

psychiatrygeneral practicediagnosticcommunicationtemazepam
VIChospital2010

Finding into death of Nicole Joy Millar

42y · Female·Complications of cutaneous burns

Nicole Joy Millar, 42, died from severe burns inflicted by her intimate partner in a premeditated attack at a petrol station. She had disclosed prior intimate partner violence to support services but remained isolated an…

emergency medicineplastic and reconstructive surgerycommunicationsystemdiazepam
QLD2009-12-16

Myers, Robert Hayes

63y · Male·Myocardial infarction as a result of long standing ischaemic heart disease and a…

Robert Myers, a 63-year-old prisoner with long-standing ischaemic heart disease and prior coronary artery bypass grafts, died from myocardial infarction three days after discharge from the Princess Alexandra Hospital. He…

cardiologygeneral practice
SAaged care2009-10-16

Coroner's Finding: CHILDS Hayden William

77y · Male·hypoxic-ischaemic encephalopathy and cerebral infarction due to upper airway obs…

A 77-year-old man with advanced dementia died from hypoxic-ischaemic encephalopathy caused by upper airway obstruction from a handkerchief. An agency carer placed a handkerchief in his breast pocket during morning care, …

geriatric medicineemergency medicinecommunicationsystem
QLDhospital2009-10-08

Kerkvliet, Kristen

1y · Female·acute myocardial infarction secondary to Kawasaki's Disease

Kristen Kerkvliet, aged 14 months, died from acute myocardial infarction secondary to Kawasaki's Disease. She presented to Gympie Hospital severely underweight and malnourished on 3 February 2006, having failed to thrive…

paediatricsgeneral practicediagnostic
QLDaged care2009-10-01

Streader, Leon

68y · Male·coronary atherosclerosis worsened by heat stroke

Leon Streader, a 68-year-old man with schizophrenia, epilepsy, obesity, and coronary artery disease, died from coronary atherosclerosis worsened by heat stroke whilst residing in a level-3 accredited hostel on an extreme…

general practicepsychiatrysystemdelaybenztropine
WAhospital2009-09-30

Inquest into the Death of Watmore

17y · Male·fatal asphyxia resulting from severe upper airway obstruction secondary to acute…

Kieran Watmore, a fit 17-year-old male, died from fatal asphyxia at Albany Regional Hospital on 28 August 2008 while being treated for acute tonsillitis. He presented to ED on 27 August with severe throat pain and was pr…

emergency medicinegeneral practicediagnosticcommunicationmorphine
WAhospital2009-09-11

Inquest into the Death of Gordon

1y · Female·pneumonia (staphylococcal pneumonia with bilateral bacterial pneumonia)

Jezelle Lisa Gordon, a 1-year-old child, died of staphylococcal pneumonia on 26 February 2006 in Port Hedland, Western Australia. She presented to Halls Creek Hospital on 25 February with fever, elevated respiratory rate…

general practiceemergency medicinediagnosticdelayparacetamol
SAcommunity2009-08-17

Coroner's Finding: TURNER Brian Raymond

59y · Male·ischaemic heart disease due to coronary atherosclerosis

Brian Raymond Turner, 59, died from ischaemic heart disease due to coronary atherosclerosis following an out-of-hospital cardiac arrest in a medical clinic car park. He experienced symptoms of chest discomfort and breath…

cardiologyemergency medicinecommunicationdelay
WAhospital2009-08-13

Inquest into the Death of Greeuw

45y · Female·aspiration of vomitus with bowel obstruction due to faecal impaction

Vicki Margaret Greeuw, a 45-year-old woman with schizoaffective disorder, died on 13 May 2007 at Albany Regional Hospital from aspiration of vomitus secondary to bowel obstruction due to severe faecal impaction. She had …

psychiatrygeneral practicediagnosticcommunicationchlorpromazine
SAhospital2009-08-12

Coroner's Finding: HOPE Maria Kate

55y · Female·hypoxic brain injury complicated by aspiration pneumonia

A 55-year-old woman with chronic schizophrenia died from hypoxic brain injury after suffocating herself with a plastic bin liner while hospitalised in a rural hospital. She was admitted following a disturbance where she …

general practicepsychiatrycommunicationdiagnosticolanzapine
SAhospital2009-07-30

Coroner's Finding: BRUNT Sidney

65y · Male·acute right subdural haematoma

Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…

general practiceemergency medicinemedicationcommunicationwarfarin
SAaged care2009-06-26

Coroner's Finding: DAVIES Harold Leslie

87y · Male·multi organ failure due to septic shock complicating urinary tract infection and…

An 87-year-old man with atrial fibrillation on warfarin developed septic shock and multi-organ failure following traumatic bladder catheterisation. Two catheterisation attempts occurred on 15 July 2005: an unsuccessful a…

general practiceurologyproceduralcommunicationwarfarin
SAhospital2009-06-24

Coroner's Finding: LINNELL Sienna Jools

0y · Female·Group B Streptococcus infection

A 7-hour-old neonate died from early-onset Group B Streptococcus (GBS) infection contracted during labour. The mother's GBS screening test at 35-37 weeks gestation was reported negative, and no antibiotic prophylaxis was…

obstetricsgeneral practicesystemcommunication
SAhome2009-06-04

Coroner's Finding: PROBY Zak Dean

27y · Male·combined effects of penetrating injuries (crossbow arrows) to heart and brain

Zak Dean Proby, 27-year-old Aboriginal male, died from penetrating injuries from crossbow arrows to the heart and brain during a police siege on 21 June 2006. He had exhibited paranoid and disturbed behaviour for 9 days …

emergency medicinegeneral practicecommunicationmarijuana
SAhospital2009-05-22

Coroner's Finding: ROBERTS Jarrad Delroy

10y · Male·sepsis (fusobacterium necrophorum) complicating right otitis media

Jarrad Roberts, a 10-year-old with learning disabilities and likely ADHD, died from sepsis due to untreated right otitis media caused by Fusobacterium necrophorum. He had been acutely ill for 5-7 days before finally seei…

paediatricsgeneral practicedelaysystemamoxicillin
189909199

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