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VIChospital2026-02-27

Finding into death of PDR

78y · Male·Acute pancreatitis

A 78-year-old man with a long history of mental illness and multiple chronic physical conditions died from acute pancreatitis on 12 May 2025, nine days after presenting with nausea and vomiting at Thomas Embling Hospital…

emergency medicinepsychiatryolanzapine
VIChome2025-06-05

Finding into death of Caine David Knight

26y · Male·Cardiomegaly in a man with Prader-Willi syndrome

Caine David Knight, aged 26, died from cardiomegaly with right ventricular hypertrophy in the context of Prader-Willi syndrome and severe obesity. He had a complex medical history including obesity hypoventilation syndro…

cardiologyrespiratory medicinequetiapine
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
VICaged care2024-03-28

Finding into death of Shirley Hill Jones

85y · Female·Complications of a left ankle fracture (operated)

An 85-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, hypertension, prior stroke) sustained a left ankle fracture requiring surgical repair. A significant delay occurred in removing her pla…

geriatric medicineorthopaedic surgerycommunicationdelayoxycodone
NTcommunity2024

Inquest into the death of Road Death 44 of 2024

54y · Male·Multiple blunt force injuries from motor vehicle collision

A 54-year-old male died in a motor vehicle collision on the Arnhem Highway near Humpty Doo on 24 August 2024. He was a sober, licenced driver travelling at the speed limit with no fatigue, distraction, or seatbelt concer…

desvenlafaxine
VICaged care2023-03-22

Finding into death of S M

91y · Male·Complications of cerebrovascular and ischaemic heart disease in a man post anaph…

A 91-year-old man with known diltiazem allergy was prescribed diltiazem by a geriatrician despite documented allergy records. The geriatrician relied on the patient's verbal denial of allergies despite significant dement…

geriatric medicinegeneral practicediagnosticmedicationdiltiazem
VIChospital2014-07-28

Finding into death of Glen David Kingsun

42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…

Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…

general practiceemergency medicinemedicationcommunicationverapamil

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