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NSWhospital2025-02-21

Inquest into the death of David Freeman

46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…

A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…

emergency medicinegeneral practicediagnosticmedicationaspirin
QLDaged care2024-12-10

Non-inquest findings into the death of Mr O.

79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…

A 79-year-old man with extensive comorbidities died following multiple falls in residential aged care. He was identified as high falls risk on admission but experienced inadequate falls prevention after a second fall on …

geriatric medicineemergency medicinediagnosticmedicationaspirin
QLDhospital2024-10-18

Findings into the death of John Ainsworth

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…

neurologyemergency medicinedelaymetformin
TAShospital2024-09-30

Coroner's Finding: Newell, Warren James

71y · Male·raised intracranial pressure caused by left frontal-temporal-parietal subdural h…

Warren James Newell, a 71-year-old man with oesophageal cancer, presented with acute coronary syndrome on 29 September 2022 and was appropriately diagnosed and treated with anticoagulation and dual antiplatelet therapy. …

cardiologyemergency medicinemedicationsystemenoxaparin
SAhome2024-09-13

Coroner's Finding: Roy, William James

71y · Male·ischaemic heart disease due to coronary atherosclerosis

71-year-old man died of ischaemic heart disease due to coronary atherosclerosis while on home detention bail. He had significant cardiovascular risk factors including diabetes, peripheral artery disease, carotid atherosc…

aspirin
QLD2024-06-18

Inquest into the deaths of Shiralee Deanne Tilberoo and Vlasta Wylucki

Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…

Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…

cardiologyaddiction medicineproceduralcommunicationdiazepam
VIChospital2024-05-06

Finding into death of Errol Leslie Solly

67y · Male·Ischaemic heart disease; coronary artery atherosclerosis (stented)

A 67-year-old man with extensive cardiac history presented to the ED with recurrent ischaemic-sounding chest pain. Despite multiple episodes of chest pain during admission, initial ECGs and troponins were normal. Followi…

emergency medicinecardiologydiagnosticcommunicationmorphine
TAS2024-05-02

Coroner's Finding: Gleeson, Bernice Valma

84y · Female·left subdural haematoma resulting from head injury due to fall from standing

An 84-year-old woman suffered a fatal head injury after slipping on steps at a café in Stanley, Tasmania on 20 October 2021, resulting in a left subdural haematoma. She was appropriately transported to neurosurgical faci…

neurosurgeryemergency medicineaspirin
WAhospital2023-11-02

Inquest into the Death of Bradley James Raymond STINSON

66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…

Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arteriosclerotic cardiovascular disease, pulmonary thromboembolism, and metasta…

palliative careoncologyproceduralsystemoxycodone
TAShospital2023-10-11

Coroner's Finding: Jones, Emily Margaret Rose

82y · Female·traumatic closed head injury (subdural haematoma) resulting from a fall from sta…

Mrs Emily Jones, 82, died from subdural haematoma following an unwitnessed fall at Royal Hobart Hospital on 15 November 2021. She was admitted five days after discharge from Hobart Private Hospital where she was treated …

cardiologyemergency medicinemedicationcommunicationmetoprolol
VIChospital2023-08-01

Finding into death of Michele Valentino

81y · Male·Head injury sustained in a fall

Michele Valentino, 81, died from a head injury sustained in a fall on 20 December 2019, with death occurring on 24 December 2019. A CT angiogram at 3:45pm showed worsening intraventricular haemorrhage (IVH) that was not …

emergency medicineradiologydiagnosticcommunicationaspirin
NSWcommunity2023-08-01

Inquest into the death of Peter Gretton

64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…

Peter Gretton, a 64-year-old man imprisoned at Junee Correctional Centre, died from metformin toxicity complicated by acute renal impairment and severe lactic acidosis. His renal function deteriorated in the three to fou…

emergency medicinecardiologydiagnosticcommunicationmetformin
QLDhospital2023-07-05

Conlon, Edgar

75y · Male·End-stage renal disease, with hypertension, ischaemic heart disease, and diabete…

Edgar Hugh Sandow, a 75-year-old First Nations man, died from end-stage renal disease while incarcerated at Princess Alexandra Hospital Secure Unit. He had multiple comorbidities including heart failure, diabetes, hypert…

nephrologycardiologyaspirin
WAhospital2023-04-17

Inquest into the Death of Edward Ivan AFRICH

64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …

Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…

respiratory medicinecardiologycommunicationsystemthiamine
WA2023-03-13

Inquest into the Death of Frank ALBERT

46y · Male·atherosclerotic heart disease

Frank Albert, a 46-year-old Aboriginal man, died from atherosclerotic heart disease while incarcerated at West Kimberley Regional Prison. Although his death was caused by severe coronary artery disease unrelated to medic…

cardiologyemergency medicinesystemcommunicationquetiapine
NSWcustody2023-03-01

Inquest into the death of William Haines

37y · Male·Pulmonary thromboembolus due to left leg deep vein thrombosis

A 37-year-old Aboriginal man died of pulmonary thromboembolism due to deep vein thrombosis while incarcerated. He presented to hospital on his birthday with lethargy, shortness of breath, and tachycardia. Initial assessm…

emergency medicinecardiologydiagnosticsystemenoxaparin
VIChospital2023-02-28

Finding into death of Mrs K

81y · Female·Cardiac tamponade secondary to dissection of ascending aorta

An 81-year-old woman with hypertension and hypercholesterolaemia presented to the ED with sudden-onset central chest pain radiating to the jaw. Despite appropriate initial assessment and ruling out acute coronary syndrom…

emergency medicinecardiologydiagnosticdelayaspirin
VICaged care2023-02-23

Finding into death of H D

87y · Female·Complications following a medication administration error in a woman with multip…

An 87-year-old woman died from complications of a medication administration error at an aged care facility. During transition from paper-based to electronic medication charts in December 2020, a pharmacy data entry error…

geriatric medicinegeneral practicemedicationsystemrisedronate
QLD2023-01-25

Civic, Mirko

70y · Male·Coronary atherosclerosis

Mirko Civic, a 70-year-old prisoner with a significant cardiac history including prior myocardial infarction, hypertension, and ischaemic heart disease, died of coronary atherosclerosis in September 2018. Critical clinic…

cardiologygeneral practicediagnosticmedicationaspirin
QLDhospital2023-01-24

Smith, David Frederick

45y · Male·Haemorrhagic transformation of cerebral infarction, due to bilateral internal ca…

David Smith, aged 45, died from haemorrhagic transformation of cerebral infarction secondary to essential thrombocytosis with bilateral internal carotid artery thrombosis. He developed an acute ischaemic stroke on 9 July…

haematologyneurologysystemrivaroxaban
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