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WA2022-08-05

Inquest into the Death of Michael James HARDIE

41y · Male·haemothorax due to ruptured thoracic aortic aneurysm in a man with Marfan syndro…

A 41-year-old man with Marfan syndrome and a thoracic aortic aneurysm managed conservatively with blood pressure medications died from aneurysm rupture while imprisoned. Methylamphetamine in his system significantly elev…

cardiologyvascular surgerycommunicationsystemmethamphetamine
VICcommunity2022-07-12

Finding into death of Timothy Dale Fehring

15y · Male·Hypoxic-ischaemic encephalopathy complicating cardiac arrest in the setting of b…

Timothy Fehring, 15-year-old on a school excursion to Europe, died of hypoxic-ischaemic encephalopathy from cardiac arrest in the setting of bronchopneumonia and gastroenteritis. He developed gastroenteritis symptoms on …

paediatricsemergency medicinediagnosticcommunicationparacetamol
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
WAhospital2020-09-23

Inquest into the Death of PT (Name Subject to Suppression Order)

5y · Female·aspiration of vomit with microscopic early pneumonia, in a child with a history …

A five-year-old girl with cerebral palsy and epilepsy resulting from non-accidental head injuries at two months old died from aspiration of vomit with early pneumonia. Critical lessons: bruising in non-ambulant infants i…

paediatricsgeneral practicediagnosticcommunicationtopiramate
NSW2020-04-22

Inquest into the death of Robert HOWLETT

74y · Male·Ischaemic heart disease and coronary atherosclerosis

Mr Robert Howlett, a 74-year-old man with extensive comorbidities including chronic lung disease, hypertension and severe hearing disability, died of ischaemic heart disease and coronary atherosclerosis while in custody …

cardiologygeneral practicecommunicationnifedipine
VIChospital2019-04-04

Finding into death of Isabella Estelle Rees

1y · Female·Gastrointestinal haemorrhage due to aorto-oesophageal fistula caused by lodged b…

Isabella Rees, aged 14 months, presented to Sunshine Hospital ED four times over 19 days with fever, vomiting and later haematochezia. A button battery lodged in her oesophagus caused progressive caustic injury leading t…

emergency medicinepaediatricsdiagnosticcommunicationondansetron
QLDhospital2017-11-23

Jacobs, Roy Rodney

48y · Male·Coronary artery disease precipitating acute myocardial infarction resulting in c…

Roy Rodney Jacobs, a 48-year-old Aboriginal man with cirrhosis and coronary artery disease, died of acute myocardial infarction at Cherbourg Hospital after presenting three times over 28-30 August 2016 with chest pain an…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
QLD2017-08-04

Mrs H - Non-inquest findings

76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed

A 76-year-old woman with chronic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital fo…

general medicinegastroenterologydiagnosticcommunicationibuprofen
NSWhospital2017-03-16

Inquest into the death of Bridgett CURRAH

1y · Female·aspiration of gastric contents due to recent gastroenteritis and vomiting leadin…

Bridgett Currah was a 19-month-old girl with complex medical needs including cyanotic congenital heart disease, gastro-oesophageal reflux, and feeding difficulties. She presented to Mildura Base Hospital on 21 May 2013 w…

paediatricsemergency medicinediagnosticcommunicationomeprazole
QLD2016-07-06

Mickelo, Garnett Allan

48y · Male·myocardial infarction due to coronary atherosclerosis (medically treated)

Garnett Mickelo, aged 48, died from myocardial infarction due to coronary atherosclerosis while in custody at Woodford Correctional Centre on 24 November 2012, shortly after discharge from Princess Alexandra Hospital fol…

cardiologycardiothoracic surgerymedicationcommunicationisosorbide mononitrate
NSW2015-11-27

Inquest into the death of Madeleine Duffy

18y · Female·asphyxiation and respiratory failure on a background of severe dystonic quadripl…

Madeline Duffy, 18 years old with severe dystonic quadriplegic cerebral palsy, died from asphyxiation and respiratory failure while in respite care. She was positioned on her side in bed with pillows, contrary to her usu…

rehabilitation medicineneurologycommunicationdelaybaclofen
NSWhospital2015-11-16

Inquest into the death of Ivy Dwyer

18y · Female·Severe cardiogenic shock caused by myocarditis as a consequence of an unknown vi…

Ivy Dwyer, 18, died from viral myocarditis causing cardiogenic shock. She presented over weeks with progressive non-specific symptoms (nausea, vomiting, fatigue, cough) consistent with viral illness. A locum GP diagnosed…

general practiceemergency medicinediagnosticcommunicationloperamide
VIChospital2015-04-02

Finding into death of Maria Teresa Nigro

53y · Female·hanging

Maria Nigro, a 53-year-old woman with depression and recent medication overdose, was admitted involuntarily to Werribee Mercy Hospital's Low Dependency Unit (LDU) on 4 February 2009. Despite a risk assessment on 9 Februa…

psychiatrycommunicationsystemsertraline
WAhospital2015-02-26

Inquest into the Death of Peta Susan DOIG

58y · Female·pneumonia and cardiac failure complicated by hypoxic brain injury

A 58-year-old woman with autism and severe intellectual disability died from pneumonia and cardiac failure complicated by hypoxic brain injury following cardiac arrest. She had been institutionalised at Graylands Hospita…

psychiatryintensive carediagnosticdelayazithromycin
WAhospital2014-12-30

Inquest into the Death of Gheorghe Gruici

71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…

Gheorghe Gruici, a 71-year-old life-sentenced prisoner, died of organ failure from chronic renal failure, infective endocarditis, and chest infection. Over 15 years in custody, he developed multiple comorbidities includi…

general medicinenephrologyomeprazole
WAhome2014-10-27

Inquest into the Death of Baby Xavier

Unknown·unascertained

An 8-week-old infant in out-of-home care died suddenly while asleep in a porta cot. Post-mortem examination revealed no infectious disease, injury, or toxicological abnormality. The cause remained unascertained despite e…

paediatricspathologyomeprazole
VIChospital2014-09-30

Finding into death of Iman Kassis

46y · Female·hemopericardium secondary to dissection of the thoracic aorta

Iman Kassis, a 46-year-old woman with Ehlers-Danlos Syndrome Type 4 and known severe aortic regurgitation with dilated ascending aorta, presented to the ED on 8 October 2008 with sudden-onset severe throat pain, bradycar…

emergency medicinecardiologydiagnosticdocumentationflecainide
QLD2013-12-02

Currie, Gordon

58y · Male·coronary atherosclerosis

Gordon Currie, 58, died of coronary atherosclerosis while performing manual labour (whipper snipping) at a banana plantation within Palen Creek Correctional Centre. He complained of left shoulder pain, which was likely r…

forensic medicinecorrectional healthomeprazole
VICaged care2013-11-21

Finding into death of Ivo John Martinov

58y · Male·Unascertained causes

A 58-year-old man with treatment-resistant schizophrenia living in aged care died suddenly 30 minutes after receiving his evening clozapine dose. Although post-mortem toxicology detected a potentially toxic clozapine lev…

psychiatrygeneral practicesystemclozapine
QLD2013-09-24

Emerton, Andrew John Joseph

43y · Male·Coronary Atherosclerosis

Andrew Emerton, a 43-year-old prisoner with a history of substance abuse and psychiatric treatment, collapsed after vigorous exercise in custody. He called for help reporting shortness of breath and was found unconscious…

cardiologyemergency medicinequetiapine

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