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SAhospital2009-05-21

Coroner's Finding: FARKAS Karl Derek

45y · Male·intracerebral haemorrhage caused by rupture of arterial aneurysm

A 45-year-old man with an intracerebral haemorrhage from a ruptured aneurysm presented to an emergency department and general practice on multiple occasions in October 2005 with headache, vomiting, dizziness, and neck st…

emergency medicinegeneral practicediagnosticcommunicationaspirin
QLDaged care2009-05-05

Hoy, Raleigh

41y · Male·Dilated cardiomyopathy

Raleigh Hoy, a 41-year-old man with schizophrenia and autistic spectrum disorder, died of dilated cardiomyopathy at a residential care facility (Tarampa After Care Centre) in Queensland in January 2007. While his mother …

psychiatrygeneral practicecommunicationsystemclozapine
WAcommunity2009-04-24

Inquest into the Death of Halford

17y · Female·Multi System Failure following acute onset (Acute Diabetic Ketoacidosis) Diabete…

Lee Rebecca Halford, a 17-year-old girl, died of acute diabetic ketoacidosis (DKA) following undiagnosed Type 1 diabetes. She initially presented to a GP with vomiting on 27 February 2007, diagnosed with gastroenteritis.…

general practiceemergency medicinediagnosticcommunicationmetoclopramide
QLDhome2009-04-24

Joy, Michael Joseph

43y · Male·intra-abdominal haemorrhage due to traumatic rupture of splenic blood vessels du…

Michael Joseph Joy, a 43-year-old man with Wilson's disease requiring wheelchair mobility and residential care, died from intra-abdominal haemorrhage due to splenic vessel rupture following a fall in his bathroom on 24 F…

general practicepathologysystemcommunication
SAhome2009-04-17

Coroner's Finding: PARROTT Jenisha Diandra (aka White)

7y · Female·streptococcus pneumoniae sepsis complicating retropharyngeal abscess

A 7-week-old infant died from streptococcus pneumoniae sepsis complicating retropharyngeal abscess. Three days before death, a report was made to child protection services alleging the father had shaken the infants. A ge…

general practiceemergency medicinediagnosticsystem
SAcommunity2009-03-30

Coroner's Finding: DALLING Brian Terrance and SALOTTI Jack William and GRZYWACZ Richard John and SOBEY Brian Leslie

Male·acute myocardial infarction due to coronary artery disease (all four); specific …

Four rural South Australian men (aged 42-76 years) died from acute coronary syndrome in 2004-2006. All presented to country medical practitioners with symptoms suggestive of acute coronary syndrome but were not identifie…

general practiceemergency medicinediagnosticcommunicationaspirin
QLDhome2009-03-16

Blake, Melissa Maree

Female·Drowning (suicide)

Melissa Maree Blake died by suicide by drowning on 16 January 2007 while receiving community-based treatment for psychotic depression, which developed following a miscarriage. She was referred to Sunshine Coast Mental He…

psychiatrygeneral practicemedicationcommunicationescitalopram
NSWcommunity2009-02-27

02anonfinding

54y · Male·Died by hanging while suffering from the effects of Post-traumatic Stress Disord…

A 54-year-old NSW police officer died by suicide while suffering from PTSD and Bipolar Disorder. He had witnessed multiple traumatic incidents during his 25-year career and was diagnosed with Bipolar Disorder in 2003. Fr…

general practicepsychiatrylithium
VIChospital2009-01-27

Finding into death of Zakaria Tartourssi

0y · Male·Respiratory insufficiency; interstitial fibrosis and low-grade pneumonitis of pr…

Zakaria Tartoussi died at age 43 days from respiratory insufficiency due to interstitial fibrosis and low-grade pneumonitis of probable viral aetiology. He presented for medical attention five times in six weeks with sym…

general practicepaediatricsdiagnosticcommunicationparacetamol
QLDhospital2008-12-15

Van Putten, Patricia

49y · Female·Respiratory failure sequential to ingestion of Glyphosate due to depression and …

Patricia Van Putten, a 49-year-old retired teacher, died by suicide via glyphosate ingestion on 18 February 2006, four days after discharge from psychiatric hospitalization for a serious self-harm attempt (throat lacerat…

psychiatrygeneral practicecommunicationsystemdosulepin
SA2008-11-28

Coroner's Finding: GILL Andrew Stephen and SCHAER Simon

26y · Male·severe closed head injury associated with severe fractures of the cranial vault …

Two remand prisoners died by jumping from mezzanine floors at Adelaide Remand Centre. Andrew Gill (26) died 2 June 2005 after jumping 1 June; Simon Schaer (70) died 15 December 2005. Critical failure: police possessed in…

psychiatryemergency medicinecommunicationsystemclonazepam
QLDhome2008-09-12

Doheny, Dominic Raphael

36y · Male·morphine toxicity

A 36-year-old man with morbid obesity, possible sleep apnoea, and respiratory symptoms died from morphine toxicity after taking three 100mg MS Contin tablets within 6 hours, despite being opioid-naïve. He presented to ED…

emergency medicinegeneral practicemedicationprescribingmorphine
NTcommunity2008-09-01

Inquest into the death of Robert Daly

38y · Male·coronary atherosclerosis

Robert Taylor Daly, a 38-year-old Aboriginal man, died of coronary atherosclerosis with severe coronary artery blockage and pulmonary edema. He collapsed in a drinking area after consuming alcohol while acutely ill with …

emergency medicinecardiologydiagnosticcommunicationcough mixture
NTcommunity2008-09-01

Inquest into the death of Peter Limbunya

78y · Male·pneumonia with dehydration and exposure to heat as contributing factors

Peter Limbunya, a 78-year-old Aboriginal elder, died from pneumonia complicated by dehydration and exposure after being left unattended at a remote airstrip following hospital discharge. He was not accompanied by a requi…

emergency medicinegeneral practicecommunicationsystem
SAhome2008-06-25

Coroner's Finding: Baby Safe Sleeping Practices

Zara Schupelius: suffocation; Callum Smith: undetermined; Jake Hackett: suffocat…

Concurrent inquests into five sudden unexpected deaths in infancy (SUDI), three attributed to suffocation and two undetermined but with suffocation as a significant possibility. All deaths occurred in infants aged 2-7 mo…

forensic medicinepaediatricssystemcommunication
SAaged care2008-06-06

Coroner's Finding: MANN Richard Lesley

45y · Male·choking on food

Richard Mann, a 45-year-old man with intellectual disability and psychiatric illness residing in an institutional setting (Strathmont Centre infirmary), died from choking on food. Critical failures in observation and mon…

psychiatrygeneral practicemedicationcommunicationhaloperidol
VIChome2008-06-04

Finding into death of Kath Bergamin

37y · Female·unlawful killing

Kath Bergamin, a 37-year-old woman, disappeared from her home in Wangaratta, Victoria on 18 August 2002. She had recently left her husband John following years of psychological and physical abuse, obtaining intervention …

psychiatrygeneral practicesystemcommunicationcitalopram
QLDcommunity2008-05-19

Mountford-Smith, Trevor Bertram

58y · Male·drowning

Trevor Mountford-Smith, a 58-year-old nuclear engineer, disappeared during a holiday on 27 March 2003 and is presumed to have drowned. He had recently been diagnosed with significant cognitive impairment affecting inform…

infectious diseasesneurology
WAcommunity2008-02-25

Inquest into the Death of Kimberley Coronial Report

Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…

This coronial inquiry examined 22 deaths of Aboriginal people in the Kimberley region of Western Australia between 2000 and 2007. Seventeen were self-harm deaths, with four additional accidental deaths and one homicide. …

public healthpsychiatrysystemdelayalcohol
NThome2008-02-13

Inquest into the death of Billy Martin

33y · Male·accidental drowning

Billy John Martin, a 33-year-old man, drowned in a residential swimming pool while heavily intoxicated (blood alcohol 0.370%), having sustained recent head trauma. He had visited a doctor five days prior with post-concus…

general practiceemergency medicinesystemalcohol
190919299

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