31 results
43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…
Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …
74y · Male·Pulmonary thromboembolism in the setting of deep leg vein thrombosis
A 74-year-old man died from pulmonary thromboembolism with deep vein thrombosis 10 days after elective umbilical hernia repair. He received appropriate VTE prophylaxis (mechanical and pharmacological) intraoperatively an…
71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…
68y · Male·Cerebrovascular disease
John Raymond Ainsworth, a 68-year-old prisoner, died of cerebrovascular disease following a severe stroke on 25 November 2020. He had poorly controlled Type II diabetes, hypertension, and high cholesterol. Prior to his a…
60y · Female·sepsis due to community acquired pneumonia
Lynne Patricia Fisher, 60, presented to Mount Barker Hospital ED on 26 September 2018 with bilateral community-acquired pneumonia and was discharged after 6.5 hours despite clinical deterioration. She collapsed at home w…
70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia
70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…
59y · Female·Complications of Trisomy 21
Catherine Mary Lyons, aged 59 with trisomy 21 and moderate intellectual disability, died from complications of her underlying condition. She presented with respiratory tract infection symptoms on 8 December 2022 and was …
Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…
This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…
81y · Male·metastatic rectal adenocarcinoma with infected necrotic sacral ulcer
Raymond Saxon Beahl, 81, died of metastatic rectal adenocarcinoma complicated by an infected necrotic sacral ulcer. He was admitted to Oakden Older Persons Mental Health Service with severe dementia-related behavioural d…
69y · Male·Myocardial infarction secondary to coronary artery atherosclerosis in the settin…
Mr Crabtree, a 69-year-old man with intellectual disability, COPD, emphysema and heavy smoking history, presented to the ED with respiratory distress on 26 May 2016. He was diagnosed with infective exacerbation of COPD a…
51y · Male·blunt trauma of the chest sustained in a motor vehicle crash; hypovolemic shock …
A 51-year-old man with schizophrenia, bipolar disorder, chronic pain, and substance use disorder died from blunt chest trauma following a motor vehicle crash. He had a history of two previous crashes associated with high…
61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a c…
Kelvin Moulds, a 61-year-old man, died of hypoxic encephalopathy following a cardiac arrest caused by self-removal of a central venous catheter (CVC) on day 14 post-bilateral lung transplant. The CVC was still in situ de…
75y · Female·general inanition and pneumonia on a background of end-stage dementia
75-year-old woman with end-stage mixed dementia (vascular and Alzheimer's) died from general inanition and pneumonia. She was detained under a Mental Health Act Inpatient Treatment Order due to severe aggression and beha…
74y · Male·Ischaemic heart disease and coronary atherosclerosis
Mr Robert Howlett, a 74-year-old man with extensive comorbidities including chronic lung disease, hypertension and severe hearing disability, died of ischaemic heart disease and coronary atherosclerosis while in custody …
38y · Male·Sepsis complicating bronchopneumonia and chest wall abscess in the setting of an…
A 38-year-old man with secondary adrenal insufficiency from childhood chemoradiation died from sepsis complicating a chest wall abscess and bronchopneumonia, precipitated by an adrenal crisis. He presented to his GP with…
96y · Female·Pseudomonas aeruginosa sepsis secondary to infected leg ulcers, complicated by m…
A 96-year-old woman with diabetes, dementia and a chronic blistering skin condition developed progressively worsening leg ulcers with exposed tendons while resident in an aged care facility. Despite multiple medical revi…
12y · Male·Cardiac haemorrhage due to or as a consequence of congenital aortic stenosis (su…
Joshua Statis, a 12-year-old with complex congenital aortic stenosis, died 18 days after a redo Konno procedure and aortic valve replacement when a CardioCel patch to the right ventricular outflow tract (RVOT) ruptured, …
47y · Male·Aspiration pneumonia in the setting of Down syndrome
Andrew Bond, a 47-year-old man with Down syndrome and significant disabilities, died from aspiration pneumonia after a chronic decline in swallowing function. He had oropharyngeal dysphagia since 2007 and Alzheimer's dis…
45y · Male·Cardiorespiratory arrest due to coronary artery disease, severe psychosis requir…
Stanley King, a 45-year-old man with severe psychosis, coronary artery disease, and obesity, died from cardiorespiratory arrest triggered by antipsychotic-induced laryngeal dystonia. Admitted involuntarily for acute psyc…
69y · Male·metastatic squamous cell carcinoma of the lung with chronic obstructive lung dis…
Barry John Matthews, aged 69, died of metastatic squamous cell carcinoma of the lung with chronic obstructive lung disease at an aged care facility while subject to a section 32 detention order. He had undergone chemothe…
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