Coronial
SAhospital

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. Report an inaccuracy.

Specialties

intensive carepsychiatryemergency medicinetoxicologycardiothoracic surgery

Drugs involved

alcoholvenlafaxineolanzapineescitalopram

Clinical conditions

caustic soda toxicityoesophageal perforationmediastinitisacute kidney injuryuremic encephalopathyseptic shockcerebral oedemacerebellar herniationanion gap metabolic acidosisdepressiondrug-induced psychosis

Procedures

continuous venovenous haemodiafiltrationethanol infusiondialysisvasopressor infusionCT imaging

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
Full text

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.