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VICaged care2022-10-14

Finding into death of Beryl Eileen Brindley

74y · Female·Diabetic ketoacidosis

A 74-year-old woman with Type 1 diabetes died from diabetic ketoacidosis (DKA) in an aged care facility. Between 7-10 December 2016, her blood glucose levels remained persistently elevated (>33 mmol/L) despite escalating…

general practiceendocrinologydiagnosticcommunicationinsulin
QLDhospital2022-09-23

Adams, Adrian John

76y · Male·Small bowel obstruction and acute renal failure, due to or as a consequence of m…

Adrian Adams, aged 76, died in Princess Alexandra Hospital from small bowel obstruction and acute renal failure secondary to metastatic colorectal cancer. He was serving an eight-year sentence for sexual offences at the …

palliative careemergency medicinemedicationsystemdutasteride
TAShospital2022-09-21

Coroner's Finding: Brown, Sandra Anne

54y · Female·hypothermia, likely related to drug toxicity

Sandra Anne Brown, a 54-year-old woman with multiple chronic conditions including COPD, diabetes, bipolar disorder and epilepsy, died from hypothermia likely related to drug toxicity. She presented to the ED with breathi…

emergency medicinerespiratory medicinecommunicationsystemfluvoxamine
VIC2022-09-09

Finding into death of Gregory Paul Sedgman

42y · Male·Complications post polypharmacy toxicity

Gregory Sedgman, aged 42, died from polypharmacy toxicity after consuming excessive prescription medications at a post-sentence supervision residential facility. He had deliberately accumulated medications despite a seiz…

psychiatrytoxicologymedicationcommunicationoxycodone
SAhome2022-08-15

Coroner's Finding: Bruns, Corbus Kenneth

64y · Male·sodium nitrite poisoning

A 64-year-old man on home detention bail died from intentional sodium nitrite poisoning. He had a documented history of depression, anxiety, and suicidal ideation. His GP noted he was 'pretty much suicidal' in February 2…

general practicepsychologycommunicationsodium nitrite
VIChospital2022-08-10

Finding into death of Dimitrios Alexandrou

52y · Male·Gastric adenocarcinoma

Dimitrios Alexandrou, a 52-year-old man with severe cerebral palsy, intellectual disability, and drug-resistant epilepsy, died from gastric adenocarcinoma. He presented in July 2021 with weight loss and reduced appetite;…

oncologypalliative careepilim ec
VIChome2022-07-20

Finding into death of Brian Kevin Scurrah

75y · Male·Complications of multiple myeloma (palliated)

Brian Kevin Scurrah, a 75-year-old man with intellectual disability living in a supported residential service, died from complications of multiple myeloma. He was diagnosed with advanced multiple myeloma in June 2021 fol…

oncologypalliative careamiodarone
VIC2022-06-03

Finding into death of Micky Craig Revera

40y · Male·Unascertained; opioid withdrawal-related seizure or cardiac arrhythmia could not…

Micky Craig Revera, a 40-year-old man with chronic heroin addiction, died in Melbourne Assessment Prison on 18 February 2019 from unascertained causes. He was arrested on 12 February after erratic driving, underwent poli…

emergency medicineforensic medicinediagnosticcommunicationheroin
VIChome2022-05-20

Finding into death of Mandy Hawkey

51y · Female·Mixed drug toxicity

A 51-year-old woman with longstanding treatment-resistant depression, chronic pain, and suicidal ideation died from mixed drug toxicity. She intentionally overdosed on multiple medications including benzodiazepines, anti…

general practicepsychiatrymedicationcommunicationflunitrazepam
NSWmental health2022-05-06

Inquest into the death of Diane EASTCOTT

71y · Female·ischaemic cardiovascular disease

Diane Eastcott, a 71-year-old involuntary mental health patient, died of ischaemic cardiovascular disease on 10 July 2018 at Macquarie Hospital. Following an unwitnessed fall on 22 June 2018, she was admitted to Ryde Hos…

emergency medicinecardiologymedicationcommunicationmetoprolol
VIChome2022-03-25

Finding into death of Ms WJ

59y · Female·Sepsis in a woman with epilepsy, cerebral palsy and haemochromatosis

A 59-year-old woman with cerebral palsy, epilepsy, and intellectual disability died of sepsis from a urinary tract infection (urosepsis) caused by E. coli and Proteus mirabilis. She had four hospital presentations in the…

emergency medicinegeneral medicinecommunicationsystemmetoclopramide
VIChospital2022-01-20

Finding into death of H I

49y · Female·Acute myocardial infarction secondary to giant-cell arteritis and atherosclerosi…

49-year-old woman died from acute myocardial infarction secondary to giant-cell arteritis of coronary arteries. On 26 November, she presented to her GP with left-sided chest pain described as atypical and unlikely ischae…

general practiceemergency medicinediagnosticsystemmetoclopramide
VIChospital2021-09-21

Finding into death of AH

37y · Male·Mixed Drug Toxicity (Oxycodone, Quetiapine, Pregabalin and Clonazepam)

A 37-year-old man died from mixed drug toxicity (oxycodone, quetiapine, pregabalin, clonazepam) after ingesting unknown quantities of his own medications in an ED. He presented with trauma symptoms four days post-motor v…

emergency medicinetoxicologydiagnosticcommunicationoxycodone
VICcommunity2021-08-16

Finding into death of Phillip John Sealey

62y · Male·Diabetic ketoacidosis in a man with coronary atherosclerosis and cardiomegaly

Phillip Sealey, 62, presented to his local GP on 27 June 2019 with three weeks of thirst, urinary frequency, nocturia, blurred vision, dizziness and vomiting. The GP diagnosed hypertension and suspected diabetes mellitus…

general practiceemergency medicinediagnosticdelayfentanyl
VICaged care2021-05-24

Finding into death of Julie-Anne Marie Kettle

56y · Female·Bronchopneumonia in the setting of supratherapeutic lithium levels

Julie-Anne Kettle, a 56-year-old woman with intellectual disabilities residing in a group home, died from bronchopneumonia in the setting of supratherapeutic lithium levels. She was on lithium 1250 mg/day for psychiatric…

general practicepsychiatrydiagnosticdelaylithium
VIChospital2021-05-18

Finding into death of David John Campbell

59y · Male·Intracerebral haemorrhage

A 59-year-old man imprisoned at Hopkins Correctional Centre collapsed on 16 July 2019 with a left thalamic intracerebral haemorrhage with intraventricular rupture. He was transferred to Royal Melbourne Hospital where an …

neurosurgeryintensive carelevetiracetam
TAShome2021-05-10

Coroner's Finding: Stocks, Michelle Jayne

46y · Female·Accidental mixed prescription drug toxicity (tramadol, amitriptyline, codeine, d…

Michelle Jayne Stocks, aged 46, died from accidental mixed prescription drug toxicity in December 2018. She had complex medical conditions including emphysema, fibromyalgia, and chronic pain, managed by her GP Dr Q. retu…

general practicepharmacydiagnosticmedicationtramadol
VIChome2021-03-19

Finding into death of Jessinda Kiroyan

41y · Female·Nitrate/nitrite toxicity

Jessinda Kiroyan, a 41-year-old woman with a longstanding history of bipolar affective disorder, died from nitrate/nitrite toxicity in May 2019 after intentionally ingesting sodium nitrite obtained from a food ingredient…

psychiatryforensic medicinesodium nitrite
QLD2020-12-11

Martyn, John Francis Alex

75y · Male·Metastatic prostatic carcinoma

A 75-year-old Indigenous man died from metastatic prostate cancer while in prison custody. Diagnosed with cancer in 2012, he also had haemophilia A, ischaemic heart disease, and prior cerebrovascular accidents. By 2016, …

palliative careoncologyoxycodone
VIC2020-12-09

Finding into death of Alma Lynette Honeychurch

76y · Female·Ludwig's angina

A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognis…

emergency medicinedentistrydiagnosticcommunicationantibiotics

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