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Coroner's Finding: TS de-identified

Deceased

TS

Demographics

47y, female

Date of death

2019-04-27

Finding date

2022-05-27

Cause of death

Traumatic closed head injury likely sustained in a fall from standing

AI-generated summary

TS, a 47-year-old woman with a 18-year history of anorexia nervosa, bulimia, and severe alcoholism, died from a traumatic closed head injury sustained in a fall from standing. At autopsy, blood alcohol concentration was 0.23% (4.5 times the legal driving limit), causing significant impairment of balance, coordination, and judgment. She had alcohol-induced cirrhosis, previous head injuries with subdural haematomas, and multiple documented falls. Clinical lessons include: recognition that chronic malnutrition and alcoholism cause osteoporosis and increased fall risk; importance of assessing fall risk in patients with eating disorders and alcohol use disorder; need for stronger intervention when patients understate alcohol consumption and have deranged liver function; and consideration of capacity assessment and safeguarding in patients with recurrent hospitalizations related to substance abuse and self-harm.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinegeneral practicepsychiatrypsychologygastroenterologyhepatologyinfectious diseasesintensive careorthopaedic surgeryrespiratory medicineendocrinologydietetics

Error types

communicationsystem

Drugs involved

alcoholdoxycyclineguaiphenesin

Clinical conditions

anorexia nervosabulimiaalcoholismalcohol-induced cirrhosisosteoporosisdepressionanxietyamenorrheafatty liver diseasedyslipidaemiamallory weiss tearsalcohol withdrawal seizuresuicidal ideationpneumoniasepsisacute malnutritionlactic acidosisketoacidosis from starvationsubdural haematomasubarachnoid haemorrhageoccipital fractureradial nerve palsychronic humerus infection

Procedures

gastroscopyCT scan of brainopen reduction and internal fixation of humerus fractureintubation

Contributing factors

  • Chronic alcoholism with blood alcohol concentration of 0.23% at time of death
  • Alcohol-induced cirrhosis of the liver
  • Severe malnutrition and anorexia nervosa
  • Osteoporosis secondary to chronic malnutrition and alcohol abuse
  • History of previous head injuries with subdural haematomas
  • Multiple documented falls
  • Impaired balance and coordination from acute alcohol intoxication
  • Chronic eating disorder with purging behavior
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.