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WA2022-05-20

Inquest into the Death of Kevin Ernest McCRACKEN

58y · Male·Hypertensive and valvular heart disease

Kevin McCracken, 58, died of hypertensive and valvular heart disease following sudden cardiac collapse in a prison pre-release unit. He had complex pre-existing cardiac disease including previous valve replacement and ao…

cardiologycorrectional healthsystemmedicationwarfarin
VIChospital2022-02-28

Finding into death of H YR

77y · Female·Haemoperitoneum following cholecystectomy

A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication bu…

general surgeryintensive carediagnosticdelaywarfarin
SAaged care2021-06-30

Coroner's Finding: KOLAN Zygmunt

91y · Male·intracranial haemorrhage (subdural, subarachnoid and parenchymal) complicating r…

A 91-year-old man with Alzheimer's dementia died from intracranial haemorrhage following recurrent falls at a nursing home. He had multiple comorbidities including metastatic prostate cancer, metallic aortic valve replac…

geriatric medicineneurosurgerywarfarin
QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

Teresa Bradford, aged 40, was killed by her husband David Bradford in a premeditated domestic homicide at their Pimpama home on 31 January 2017, followed by his suicide. She died from head injuries inflicted with an axe.…

general practicepsychiatrycommunicationsystemwarfarin
TAShome2021-05-06

Coroner's Finding: Bowerman, Valerie Joy

80y · Female·acute subdural haematoma following a fall while on warfarin for atrial fibrillat…

Mrs Bowerman, aged 80, fell at home on warfarin anticoagulation and sustained a minor head injury with no initial neurological signs. Paramedic Turnbull assessed her as requiring no transport (TNR), despite her anticoagu…

paramedicineemergency medicinediagnosticcommunicationwarfarin
VIChospital2021-02-05

Finding into death of Carl David Waldon

64y · Male·Left-sided intracerebral haemorrhage associated with deep brain stimulator wire …

A 64-year-old man died from intracerebral haemorrhage along a deep brain stimulator wire tract four days after elective neurosurgery for essential tremor. He was readmitted on day 4 with suspected stroke and started on t…

neurosurgeryneurologymedicationsystemenoxaparin
QLDhospital2020-12-17

Aitkenhead, Alexander David

86y · Male·Ischaemic heart disease on a background of valvular heart disease, prostatic enl…

An 86-year-old prisoner with multiple chronic illnesses (COPD, atrial fibrillation, emphysema) died of ischaemic heart disease in a palliative care unit. He was admitted to hospital on 21 April 2019 with end-stage COPD a…

palliative caregeriatric medicinewarfarin
WAhospital2020-10-19

Inquest into the Death of Renee Desiree RUYZING

21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg

A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…

orthopaedic surgeryemergency medicinediagnosticmedicationenoxaparin
SA2020-10-12

Coroner's Finding: KEIRL Dennis Frank

63y · Male·metastatic carcinoma of the lung (small cell neuroendocrine carcinoma with poorl…

A 63-year-old male prisoner died from metastatic small cell lung cancer with adenocarcinoma features. Cancer was incidentally discovered during investigation of a deep vein thrombosis in October 2018, leading to one mont…

oncologygeneral medicinewarfarin
SAhospital2020-06-18

Coroner's Finding: THOMPSON Wayne Robert McInnes

33y · Male·Multi-organ failure due to sepsis on a background of severe ischaemic cardiomyop…

Wayne Robert McInnes Thompson, aged 33, died from multi-organ failure due to sepsis complicated by severe ischaemic cardiomyopathy. He had a complex medical history including viral myocarditis, previous intestinal resect…

cardiologyintensive carewarfarin
VIChome2020-05-29

Finding into death of Ronald John Wood

68y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis

Ronald Wood, a 68-year-old with complex medical history including prior pulmonary emboli, was treated for rectal cancer requiring chemotherapy and major surgery. Warfarin anticoagulation was appropriately ceased due to b…

colorectal surgerygastroenterologycommunicationsystemwarfarin
ACThospital2019-11-04

Inquest into death of JEFFREY BROWN

72y · Male·Haemopericardium due to anti-coagulation treatment for pulmonary thromboemboliti…

Jeffrey Brown, a 72-year-old with recent cardiac surgery (CABG), died from haemopericardium due to anticoagulation treatment for pulmonary thromboembolism. Post-mortem examination revealed fibrinous pericarditis (a known…

cardiothoracic surgerycardiologywarfarin
VIChospital2019-09-16

Finding into death of Marco Angelo Virgona

45y · Male·Aspiration pneumonia with acquired brain injury as a contributing factor

Marco Virgona, a 45-year-old man with acquired brain injury and epilepsy, died from aspiration pneumonia at Frankston Hospital on 23 May 2017. He initially presented to Ambulance Victoria in the morning with vomiting and…

emergency medicineintensive carewarfarin
VIChospital2019-08-05

Finding into death of Carmel Killackey

77y · Female·Pulmonary thromboembolism secondary to deep vein thrombosis of the left leg

A 77-year-old woman with Factor V Leiden thrombophilia and history of PE presented to a rural urgent care centre on 19 April 2017 with shortness of breath and chest pain. She was examined by Dr H. who considered but dism…

emergency medicinegeneral practicediagnosticproceduralwarfarin
QLDaged care2019-07-12

Fenech, George - Non-inquest findings

89y · Male·Congestive heart failure due to or as a consequence of ischaemic cardiomyopathy

George Fenech, 89, died of ischaemic cardiomyopathy complicated by congestive heart failure after a fall at a nursing home. He suffered a cervical spine injury (C1-C2 subluxation) and head laceration during an unwitnesse…

geriatric medicineemergency medicinecommunicationdelaywarfarin
SA2019-06-12

Coroner's Finding: WRIGHT Martin Norman

59y · Male·Chronic liver disease due to alcoholism and chronic hepatitis C infection with c…

Martin Norman Wright, aged 59, died in Yatala Labour Prison on 26 August 2015 from chronic liver disease due to alcoholism and chronic hepatitis C infection, with contributing ischaemic heart disease and chronic obstruct…

emergency medicinegeneral medicinewarfarin
QLDhospital2018-10-24

Statis, Joshua Ryan

12y · Male·Cardiac haemorrhage due to or as a consequence of congenital aortic stenosis (su…

Joshua Statis, a 12-year-old with complex congenital aortic stenosis, died 18 days after a redo Konno procedure and aortic valve replacement when a CardioCel patch to the right ventricular outflow tract (RVOT) ruptured, …

cardiothoracic surgerycardiologycommunicationdiagnosticwarfarin
VIChospital2018-10-11

Finding into death of John Richard Connelly

78y · Male·Complications of blood loss from femoral fracture sustained in harness riding in…

A 78-year-old man with ischaemic heart disease on warfarin sustained a compound femoral fracture with massive bleeding after a harness racing accident in a rural location. Despite exemplary prehospital care and timely he…

emergency medicinetrauma surgerydelaysystemwarfarin
SAhospital2018-03-29

Coroner's Finding: BUTSON Graham Joseph

81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…

Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass w…

orthopaedic surgerygeneral medicinesystemwarfarin
VIChospital2018-01-11

Finding into death of Douglas John Angus

72y · Male·Subdural haematoma in a man receiving warfarin treatment

A 72-year-old man with intellectual disability receiving 24-hour support from DHHS died from acute subdural haematoma while on warfarin therapy post-cardiac surgery. He collapsed at work with vomiting and vagueness, was …

cardiothoracic surgeryneurosurgerywarfarin

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