Coroner's Finding: Bertram, Kerry Anne
Deceased
Kerry Anne Bertram
Demographics
42y, female
Date of death
2019-05-15
Finding date
2022-06-10
Cause of death
multiorgan failure complicating hyperthermia and metabolic acidosis following suspected ingestion of caustic soda
AI-generated summary
A 42-year-old woman with long-standing depression, substance use issues, and multiple mental health presentations died from multi-organ failure following ingestion of caustic soda. She was found unresponsive at home on 13 May 2019 and admitted to hospital where she was placed on a Mental Health Act treatment order. Despite appropriate intensive care management including haemodiafiltration, ethanol infusion, and treatment of complications (oesophageal perforation, mediastinitis, acute kidney injury, septic shock), she developed cerebral oedema with herniation and died on 15 May 2019. The coroner found her care was appropriate and attentive. Key clinical lessons include recognising the severity of caustic ingestion, managing toxic metabolic complications, and addressing the underlying mental health crisis that preceded this fatal event.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- ingestion of caustic soda
- oesophageal perforation
- mediastinitis
- acute kidney injury with uremic encephalopathy
- septic shock
- cerebral oedema with cerebellar herniation
- anion gap metabolic acidosis
- underlying mental health crisis and depression
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