South Australia

Coronial Inquests published by the Australian, South Australian Coroner.

ROBERTS, Paul Scott

Inquest into the death of ROBERTS, Paul Scott

Paul Scott Roberts, aged 38, died on 7 September 2015, after setting fire to himself\r\nwhen police attended to arrest him at his home in Seaton. At the time of his death he\r\nwas being detained under home detention intensive bail supervision pursuant to the Bail\r\nAct 1985. Mr Roberts entered into that bail agreement on 31 July 2015 at the Port\r\nAdelaide Magistrates Court.

David Richard Latimer Whittle, State Coroner on 07/112/2020

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/908/ROBERTS%20Paul%20Scott.pdf’

KEN, Kenneth Ngalatji

Inquest into the death of KEN, Kenneth Ngalatji

Mr Ken was found deceased and alone in his cell when it was unlocked at about 1pm\r\non the day in question. He was located sitting in a chair. A ligature made from a\r\nbedsheet was around his neck. The sheet was tied to a wall mounted shelving unit. It\r\nwas apparent that Mr Ken had hung himself. There is no suggestion that any other\r\nperson was involved in this act and I so find. An emergency ‘code black’ was called.\r\nMr Ken was provided with immediate attempted resuscitative measures including CPR\r\nand the use of a defibrillator. South Australian Ambulance Service (SAAS) personnel\r\nattended. Timely and adequate resuscitative measures were unsuccessful. Mr Ken was\r\npronounced life extinct by a SAAS Intensive Care Paramedic at 1:55pm.

Anthony Ernest Schapel, Deputy State Coroner on 26/11/2020

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/907/KEN%20Kenneth%20Ngalatji.pdf’

WHISKEY, Louise Kitty

Inquest into the death of WHISKEY, Louise Kitty

On 31 March 2017 Ms Whiskey was admitted to the RAH by ambulance for respiratory\r\ndistress and hypoxia. On arrival she was noted to have severe multi-lobar pneumonia.9\r\nOn 4 April 2017 she absconded but returned voluntarily later that evening. On 13 April\r\n2017 she was discharged.10

Ian Lansell White, Deputy State Coroner on 03/11/2020

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/892/WHISKEY%20Louise%20Kitty.pdf’

MARSHALL, Daryl Grant

Inquest into the death of MARSHALL, Daryl Grant

Daryl Grant Marshall was born on 20 September 1955 and died at the Royal Adelaide\r\nHospital on 23 August 2017, aged 61 years. Mr Marshall was formally identified by\r\nhis brother, Mr Gary Marshall, at the Royal Adelaide Hospital.\r\n\r\nA pathology review of Mr Marshall’s clinical history was undertaken by Dr Jane\r\nAlderman from Forensic Science South Australia. In her report of that review\r\nDr Alderman has provided a cause of death for Mr Marshall as hospital acquired\r\npneumonia complicating aorto-femoral bypass surgery for peripheral vascular disease1,\r\nand I so find. The pathology review noted that Mr Marshall had a history of alcohol\r\nmisuse, back pain, gastroesophageal reflux, and discoid lupus erythematosus. \r\n

Ian Lansell White, Deputy State Coroner on 03/11/2020

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/894/MARSHALL%20Daryl%20Grant.pdf’

TAYLOR, Mervyn Maxwell

Inquest into the death of TAYLOR, Mervyn Maxwell

Mervyn Maxwell Taylor was born on 18 June 1970 and died on 17 January 2019 at his\r\nhome address. He was 48 years of age.\r\n\r\nA post mortem examination of Mr Taylor’s remains was performed by forensic\r\npathologist, Dr Stephen Wills, at Forensic Science South Australia on 21 January 2019.\r\nDr Wills’ post mortem report was tendered to the inquest.\r\n\r\nDr Wills reports that the\r\ncause of Mr Taylor’s death was atherosclerotic cardiovascular disease, and I so find.\r\n\r\n\r\nExamination of Mr Taylor’s coronary arteries revealed stenosis of 75-80%. Individuals\r\nwith significant narrowing of the major epicardial coronary arteries are at increased risk\r\nof cardiac dysfunction, arrhythmia and sudden, unexpected death. Toxicological\r\nanalysis revealed that Mr Taylor’s blood sample contained only a non-toxic\r\nconcentration of paracetamol.

Brian Malcolm Nitschke, Deputy State Coroner on 02/11/2020

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/902/TAYLOR%20Mervyn%20Maxwell.pdf’

BROWN, Graham Douglas

Inquest into the death of BROWN, Graham Douglas

Mr Brown had been cared for by his daughter, Trudy Bittner, during the last three years\r\nof his life. Mr Brown initially resided with his daughter and as his health deteriorated\r\nhe was treated as an outpatient at the Repatriation General Hospital. On 11 August\r\n2017 Mr Brown was diagnosed as suffering Alzheimer’s dementia2\r\n. From September\r\n2017, he resided at Onkaparinga Lodge Aged Care Facility. Mr Brown developed\r\naggression issues3\r\n. On 28 January 2019 following an aggressive episode Mr Brown\r\nwas admitted to the Flinders Medical Centre. Tests were conducted and he was returned\r\nto Onkaparinga Lodge for one-on-one 24-hour care.

Brian Malcolm Nitschke, Deputy State Coroner on 02/11/2020

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/895/BROWN%20Graham%20Douglas.pdf’

PEARCE, Heather Diane

Inquest into the death of PEARCE, Heather Diane

The bathroom unit was a three-metre diameter concrete water tank, converted and sold\r\nas a bathroom, purchased by Mr Pearce’s father in about 1996. He installed an\r\ninstantaneous gas hot water heater, without a flue, and did the plumbing. He covered\r\nthe outlet at the top of the heater, apparently designed to accommodate a flue, with a\r\nmetal plate. Mr Grantley Pearce played no part in that, and does not know exactly why\r\nhis father did not install a flue, or why he placed the plate on top of the heater.\r\nMr Pearce senior died some years ago.

David Richard Latimer Whittle, State Coroner on 02/11/2020

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/827/PEARCE%20Heather%20Diane.pdf’

NIXON, Viola Daphne

Inquest into the death of NIXON, Viola Daphne

Mrs Nixon was placed on a Level 1 Inpatient Treatment Order (ITO) at 2:34pm on\r\n18 October 2018 by a medical practitioner, Dr Miriam Cursaro, pursuant to section 21\r\nof the Mental Health Act 2009. The ITO was confirmed by psychiatrist, Dr Andrew\r\nRosser, on 19 October 2018 at 11:06am.\r\n2\r\n When Mrs Nixon died on 28 October 2018\r\nthe ITO had lapsed. The ITO was allowed to lapse as Mrs Nixon was by then receiving\r\ncomfort care and no longer resistant to treatment.\r\n3\r\n Despite her death not occurring\r\nwhilst under the ITO, Mrs Nixon’s death is still regarded as a death in custody as ‘the\r\ndeath occurred, or the cause of death, or possible cause of death, arose, or may have\r\narisen’ whilst Mrs Nixon was subject to an ITO. As such this is a mandatory inquest\r\npursuant to section 21(1)(a) of the Coroners Act 2003.

Brian Malcolm Nitschke, Deputy State Coroner on 02/11/2020

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/901/NIXON%20Viola%20Daphne.pdf’

MILOCCHI, Giuseppe

Inquest into the death of MILOCCHI, Giuseppe

Giuseppe Milocchi was born on 25 April 1928 and died on 21 August 2018 at the Queen\r\nElizabeth Hospital. He was 90 years of age.\r\n\r\nDr Jennifer Dang from the Queen Elizabeth Hospital provided an opinion as to the\r\ncause of Mr Milocchi’s death in her ‘Death Report to Coroner – Medical Practitioner’s\r\nDeposition’ and her opinion was that it was pneumonia leading to atrial fibrillation\r\nleading to myocardial infarction, and I so find. No post mortem or pathology review\r\nwas performed in relation to Mr Milocchi. His death was expected

CORONER on 02/11/2020

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/900/MILOCCHI%20Guiseppe.pdf’