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VIChospital2026-02-12

Finding into death of Kristy Ann Mitchener

45y · Female·Complications of sepsis secondary to sacral pressure wound in a woman with genet…

Kristy Ann Mitchener, a 45-year-old woman with severe intellectual disability, genetic developmental and epileptic encephalopathy, and oesophageal dysmotility, died from sepsis secondary to a sacral pressure ulcer despit…

general practiceemergency medicinesystemcommunicationantibiotics
VIChospital2023-04-14

Finding into death of John Edward Hadland (Millar)

38y · Male·abdominal and chest sepsis complicating iatrogenic left pneumothorax and laparot…

A 38-year-old man with chromosome 1 short arm deletion syndrome, intellectual disability, and scoliosis died from sepsis following iatrogenic pneumothorax and emergency laparotomy for small bowel obstruction. He was admi…

surgeryintensive careproceduralsystemmacrogol
NSWhospital2020-02-28

Inquest into the death of Peter ROBIN

56y · Male·Pulmonary embolism with deep vein thrombosis an antecedent cause; coronary arter…

Peter Robin, a 56-year-old man with a medical history of hypercholesterolaemia, hypertension, obesity, and depression, underwent elective dental surgery on 28 October 2015 to remove four wisdom teeth and resect a cyst. H…

oral and maxillofacial surgeryanaesthesiacommunicationsystemoxycodone
NSW2018-10-05

Inquest into the death of Carmelo Disano

71y · Male·metastatic caecal adenocarcinoma

Carmelo Disano, a 71-year-old man serving a prison sentence, died from metastatic caecal adenocarcinoma with liver and lung metastases at Long Bay Hospital in November 2015. He was diagnosed with stage IV cancer in Septe…

oncologypalliative carepalliative chemotherapy
NThospital2017-01-13

Inquest into the death of Ray Gibson

41y · Male·respiratory arrest secondary to advanced metastatic breast cancer

Ray Jabaltjari Gibson was a 41-year-old Aboriginal man with advanced metastatic breast cancer who died of respiratory arrest while in prison custody. He had been diagnosed with breast cancer in 2013 while imprisoned and …

oncologypalliative carechemotherapy
NSWhospital2014-05-09

Inquest into the death of Brendan BURNS

24y · Male·acute hydrocephalus due to undiagnosed colloid cyst of the third ventricle of th…

Brendan Burns, 24, died from acute hydrocephalus caused by an undiagnosed colloid cyst of the third ventricle. He presented with progressive severe occipital headaches, dizziness, blurred vision, nausea and vomiting over…

emergency medicineneurosurgerydiagnosticcommunicationmorphine
WAaged care

Inquest into the Death of Nola Inez DANIEL

83y · Female·Complications following fracture and surgical repair of the left hip in an elder…

Mrs Nola Inez Daniel, an 83-year-old with chronic lung disease, osteoporosis, and cardiac disease, was admitted to Regis Forrest Gardens for respite care on 24 December 2009. She sustained three falls on Christmas Day, w…

orthopaedic surgeryemergency medicinediagnosticcommunicationfentanyl

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