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QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…

emergency medicineinfectious diseasesdiagnosticdelayantacid
WAhospitalAugust 2023

Inquest into the Death of Justin DOBSON

46y · Male·sepsis following haemorrhoidectomy

46-year-old Justin Mark Dobson died from sepsis following a routine haemorrhoidectomy on 17 July 2019. He was discharged to the ward overnight but deteriorated significantly from 11:00 am on 18 July, showing hypotension,…

general surgerycolorectal surgerydiagnosticcommunicationmetronidazole
NSW2023-10-04

Inquest into the death of Melville Schrader

76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…

A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2…

oncologygastroenterologydiagnosticsystempsyllium
VICcommunity2022-12-20

Finding into death of Charles Frederick Norton

87y · Male·Ischaemic heart disease in the setting of immersion

Charles Frederick Norton, 87, was found deceased in an unsecured canal at a retirement village on 28 February 2020. He had ischaemic heart disease with severe atherosclerosis and aortic stenosis. In the week before death…

general practiceemergency medicinesystemdiltiazem
NThospital2022-01-25

Inquest into the death of Josef Lear

80y · Male·metastatic oesophageal cancer

Josef Lear, an 80-year-old prisoner, died of metastatic oesophageal cancer at the Royal Darwin Hospital Hospice on 7 March 2021. He presented with progressive dysphagia, cough, and weight loss in mid-2020, which was appr…

oncologygastroenterologycommunicationsystemibuprofen
VIChospital2021-07-22

Finding into death of Christian Joy

34y · Male·Cardiac tamponade due to hemopericardium from acute aortic dissection of the asc…

A 34-year-old previously healthy man presented to the ED with sudden-onset central chest pain. He was discharged with a diagnosis of GORD after negative troponin and symptomatic relief with antacids. A chest X-ray showed…

emergency medicineradiologydiagnosticcommunicationmorphine
NT2020-08-18

Inquest into the death of David Loader

58y · Male·carcinomatosis from unknown primary

David Kevin Loader, a 58-year-old life prisoner, died from metastatic cancer of unknown primary in January 2020. He presented with multiple episodes of back, abdominal, shoulder and rib pain between July and November 201…

general practiceoncologysodium valporate
TASmental health2019-06-28

Coroner's Finding: Hughes, Joan May

85y · Female·aspiration of gastric contents following vomiting

Joan May Hughes, age 85, died on 16 June 2014 from aspiration of gastric contents following vomiting. She was admitted to the Roy Fagan Centre with psychotic depression and was under a Mental Health Act treatment order. …

psychiatrygeriatric medicinecitalopram
WAhospital2018-03-15

Inquest into the Death of Roderick Leslie CARTER

63y · Male·Atherosclerotic Heart Disease

A 63-year-old farmer presented to a small rural hospital with atypical chest pain symptoms (also reporting indigestion, shivering, and numbness). Although a registered nurse appropriately triaged him as ATS 2 (high prior…

cardiologyemergency medicinecommunicationsystemaspirin
QLDhospital2016-10-25

Hemsley, Joanne - non-inquest findings

55y · Female·Cardiac tamponade due to haemopericardium due to acute ruptured myocardial infar…

A 55-year-old woman with extensive coronary artery disease presented for elective stent placement to her left anterior descending artery. During the procedure, a small diagonal branch vessel was occluded—a recognised com…

cardiologycardiothoracic surgerydiagnosticcommunicationticagrelor
VIChospital2016-08-19

Finding into death of Margaret Smith

91y · Female·Unascertained

Margaret Smith, a 91-year-old admitted with head strike from fall, developed moderate depression during her stay and received electroconvulsive therapy (ECT) as a compulsory patient. On 5 March 2015, she developed epigas…

psychiatrygeriatric medicinediagnosticdelaylithium
QLDhome2015-10-14

Thomas, Alexander David Joseph - Non-inquest findings

23y · Male·Beta-phenylethylamine toxicity

A 23-year-old Army private died from beta-phenylethylamine toxicity after ingesting excessive quantities of this supplement purchased online. He had a history of low mood, fatigue, and anxiety, and had self-medicated wit…

psychiatryinfectious diseasessystembeta-phenylethylamine
NSWhospital2015-07-02

Inquest into the death of N

69y · Female·Asphyxiation consistent with hanging

A 69-year-old woman admitted to Hornsby Hospital with seizures and subacute encephalopathy developed rapidly fluctuating mental state including anxiety, depression, suicidal ideation, and cognitive impairment. While indi…

neurologypsychiatrydiagnosticcommunicationphenytoin
SAhospital2013-08-27

Coroner's Finding: BALNAVES Craig Henri

43y · Male·ischaemic small intestine due to incarceration of bowel in a mesenteric defect

Craig Henri Balnaves, a 43-year-old man with treatment-resistant schizophrenia detained at Glenside Hospital under mental health orders, died from ischaemic small intestine due to bowel incarceration in a congenital mese…

general surgerypsychiatryantacid
VIChospital2013-01-31

Finding into death of Salvatore Accardo

47y · Male·pericardial tamponade secondary to ruptured dissecting thoracic aortic aneurysm …

Salvatore Accardo, a 47-year-old with previously diagnosed Marfan syndrome, died from pericardial tamponade secondary to ruptured dissecting thoracic aortic aneurysm. He presented to Austin Hospital ED on 22 February 200…

emergency medicinecardiologydiagnosticcommunicationatenolol
SA2011-09-19

Coroner's Finding: RIGNEY Vincent Norman

35y · Male·ischaemic heart disease due to coronary atherosclerosis

A 35-year-old Aboriginal man died of ischaemic heart disease due to coronary atherosclerosis whilst in prison custody. He presented with chest pain and arm tingling at 6:20am but received only Panadol and Mylanta from no…

cardiologyemergency medicinediagnosticdelayparacetamol
QLDhospital2011-06-10

Conlan, Kathleen Anne

70y · Female·Cardiac arrest caused by a combination of gastric haemorrhage and pneumonia exac…

Mrs Kathleen Anne Conlan, 70, died from cardiac arrest caused by gastric haemorrhage and pneumonia on a background of coronary artery disease. She presented with severe epigastric pain and was appropriately admitted for …

emergency medicinesurgerydelaymorphine
SAhospital2010-10-25

Coroner's Finding: CAMERON Louise Cherise

32y · Female·ischaemic heart disease complicated by upper gastrointestinal haemorrhage

A 32-year-old woman with schizophrenia presented to the emergency department with chest pain radiating to both arms, profuse sweating, and vomiting black material for several days. She also reported black stools. The fir…

emergency medicinecardiologydiagnosticproceduralmorphine
QLDaged care2010-08-19

Dossetto, Kate Emma

86y · Female·Unable to be determined

An 86-year-old woman resident in aged care died with toxicology revealing a potentially fatal concentration of sertraline (1.7mg/kg, with metabolite at 2.3mg/kg; fatal range 0.61–1.6mg/kg). A clinical pharmacologist opin…

pathologypharmacologymedicationsertraline
QLD2009-08-21

Oram, Ronald Thomas

49y · Male·Coronary artery occlusion due to, or as a consequence of, coronary artery athero…

Ronald Thomas Oram, a 49-year-old Aboriginal man, died in custody from natural causes—severe coronary artery atheroma with coronary artery occlusion. He presented to the prison nurse on 5 January 2008 with chest pain, wh…

emergency medicinecardiologydiagnosticsystemparacetamol

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