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’

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’

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’

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’

MAGGS, Eric Arthur

Inquest into the death of MAGGS, Eric Arthur

Eric Arthur Maggs was born on 30 September 1933 and died on 26 March 2019 at the\r\nRoyal Adelaide Hospital. He was 85 years of age.\r\n\r\nA post mortem examination of Mr Maggs’ remains was conducted by Dr Neil Langlois,\r\nforensic pathologist, at Forensic Science South Australia on 28 March 2019. In his\r\nreport1 of that examination Dr Langlois determined that Mr Maggs’ cause of death was\r\nischaemic heart disease, and I so find. Dr Langlois noted significant findings including\r\nsevere narrowing of the dominant right coronary artery, cardiomegaly, myocardial\r\nfibrosis, mucopurulent material trachea, emphysema and a swollen right lower leg. Dr\r\nLanglois did not find pneumonia, pulmonary emboli or cirrhosis of the liver.

CORONER on 02/11/2020

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/899/MAGGS%20Eric%20Arthur.pdf’

LAMB, Dianne Patricia

Inquest into the death of LAMB, Dianne Patricia

Dianne Patricia Lamb was born on 8 September 1951 and died on 21 April 2019 at the\r\nQueen Elizabeth Hospital in Woodville South. She was 67 years old.\r\n\r\nA pathology review based upon Mrs Lamb’s medical records was undertaken by Dr Iain\r\nMcIntyre in consultation with Dr Stephen Wills, forensic pathologist, from Forensic\r\nScience South Australia. Dr McIntyre noted a history including metastatic colorectal\r\ncarcinoma treated with surgery (bowel resection, liver resection, cholecystectomy, lung\r\nresections and chemotherapy), obstructive sleep apnoea, laparotomy and excision of\r\nteratoma, Meniere’s disease, and benign position vertigo.\r\n

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

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/898/LAMB%20Dianne%20Patricia.pdf’

HAUSLER, Christopher Raymond

Inquest into the death of HAUSLER, Christopher Raymond

Mr Hausler and his wife of 41 years, Heather, lived in Murray Bridge where Mr Hausler\r\nwas employed by the Mid Murray Council. They had three adult daughters, Rebecca,\r\nAlison and Bianca.4\r\n\r\nMr Hausler suffered from diabetes and was prescribed medication to manage this\r\ncondition, along with his cholesterol and blood pressure, but overall, he was in\r\nrelatively good health.5\r\n

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

‘http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/897/HAUSLER%20Christopher%20Raymond.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’