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TASmental health2017-11-17

Coroner's Finding: Smith, Molly Jessie

75y · Female·pyelonephritis and pneumonia

Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …

psychiatrygeneral practicediagnosticdelaycefalexin
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
QLDhospital2017-06-22

Mead, Gwendoline

73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…

73-year-old woman died 12 days after elective colorectal surgery for synchronous caecal and rectal tumours. Post-operatively, she developed persistent low urine output and intermittent hypotension managed with repeated f…

colorectal surgerygeneral surgerydiagnosticdelay5-fluorouracil
QLDhome2017-02-07

ES, a 87 year old lady

87y · Female·Multiple opioid drug toxicity (morphine and fentanyl) in combination with conges…

An 87-year-old woman with multiple comorbidities (ischaemic heart disease, emphysema, chronic kidney disease) was discharged home for palliative care after a hospital admission. Her family administered excessive doses of…

general practicepalliative caremedicationcommunicationmorphine
QLDhospital2016-07-08

Talbot, James Patrick

87y · Male·Strangulated small bowel due to adhesions from previous abdominal surgery

An 87-year-old man with diabetes, hypertension and dementia was admitted with presumed UTI and dehydration. Within 24 hours, nursing staff observed a distended abdomen and bile-stained vomiting—clinical signs of bowel ob…

general medicinenephrologydiagnosticcommunicationondansetron
NT2015-08-14

Inquest into the death of Virginia Brown

46y · Female·Cardiac arrest of unknown origin

Virginia Brown, a 46-year-old Aboriginal woman, died of cardiac arrest of unknown origin on 31 October 2014 while detained under a Mandatory Residential Treatment (MRT) order at CAAAPU (Central Australian Aboriginal Alco…

emergency medicineaddiction medicinediagnosticcommunicationsodium_valproate
NSWhospital2014-11-19

Inquests into the death of Luke WOOD

35y · Male·intraperitoneal haemorrhage from an anastomotic leak from a transplanted renal a…

Luke Wood, a 35-year-old kidney transplant recipient, died 11 days post-transplant from intraperitoneal haemorrhage due to anastomotic leak from the transplanted renal artery. While post-operative inpatient care and init…

transplant medicinenephrologycommunicationsystemlymphocyte immune globulin, anti-thymocyte globulin
VIChospital2014-09-12

Finding into death of Nola Margaret Moxon

77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression

77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission, no medical review occurred over the weekend prior to …

psychiatrygeriatric medicinecommunicationsystemvenlafaxine
ACThospital2014-03-03

Findings Into The Death Of Sukanya Thurairajah

56y · Female·hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and f…

Sukanya Thurairajah, 55-year-old with multiple comorbidities including obesity, diabetes, coronary disease, and metastatic breast cancer, underwent haemodialysis at Canberra Hospital on 29 July 2011. She had an adverse r…

anaesthesiaintensive careproceduralcommunicationhydrocortisone
VIChospital2013-05-07

Finding into death of Gurpal Sandhu

64y · Female·Lymphocytic choriomeningitis virus (LCMV)-like arenavirus infection, post liver …

A 64-year-old woman died on 3 January 2007 from a lymphocytic choriomeningitis virus (LCMV)-like arenavirus acquired through cadaveric liver transplantation. The donor had recently returned from Serbia with unexplained w…

transplant medicinehepatologycommunicationsystem
VIChospital2013-05-07

Finding into death of Carmelina Rachela Sirianni

63y · Female·Lymphocytic choriomeningitis virus (LCMV)-like virus infection; post failed rena…

A 63-year-old woman received a renal transplant from a cadaveric donor who had died of cerebral hemorrhage. She developed delayed graft function and deteriorated post-operatively, ultimately dying from a novel lymphocyti…

nephrologytransplant medicinecommunicationsystem
VIChospital2013-05-07

Finding into death of Karen Elizabeth Wilkinson

44y · Female·Lymphocytic choriomeningitis virus (LCMV)-like virus infection following failed …

A 44-year-old woman died on 1 January 2007, six days after receiving a cadaveric renal transplant. She was one of three organ recipients from the same donor who died within six days of each other from a novel lymphocytic…

transplant medicinenephrologycommunicationsystem
WA2013

Inquest into the Death of Bropho, Robert Charles

81y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis

Robert Charles Bropho, an 81-year-old Aboriginal man imprisoned since 2008 with severe medical comorbidities including insulin-dependent diabetes, hypertension, chronic renal failure, and severe ischaemic heart disease, …

cardiologygeneral medicinecommunicationsysteminsulin
VIChospital2012-12-14

Finding into death of Jeanette Brown

66y · Female·Multi-organ failure associated with haemorrhage and sepsis following cholecystec…

Mrs Jeanette Brown, 66, died from multi-organ failure following post-operative haemorrhage after elective laparoscopic cholecystectomy. Arterial clips applied to the cystic artery during surgery were inadequately secured…

general surgeryanaesthesiaproceduralcommunicationamlodipine
WAhospital2012

Inquest into the Death of Keogh

38y · Female·Pulmonary Thromboembolism

Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…

general surgeryintensive carecommunicationdelaywarfarin
VIChospital2011-02-25

Finding into death of Michael Peysack

69y · Male·Head injury post-collapse secondary to ventricular tachycardia due to ischaemic …

Mr Peysack, a 69-year-old with complex cardiac disease on Warfarin, collapsed at work with witnessed loss of consciousness and occipital laceration. Despite meeting criteria for urgent head CT imaging (age >65, head inju…

emergency medicinecardiologydiagnosticcommunicationwarfarin
SAhospital2006-05-19

Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…

77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural ta…

cardiologycardiothoracic surgerydiagnosticproceduralramipril
SAhospital2006-01-25

Coroner's Finding: RAPHAEL Glenn Howard

74y · Male·cardiac and renal failure complicating treatment of infected ischaemic toes resu…

Glenn Howard Raphael, 74-year-old admitted for infected ischaemic toe secondary to diabetes mellitus. During his 17-day hospital stay, he developed acute renal failure leading to cardiac arrest and death. Critical failur…

vascular surgerygeneral medicinemedicationcommunicationgentamicin
ACThome2003-12-23

Inquest Into The Manner And Cause Of Death Of Neil Summerell

34y · Male·extensive blood loss from acute gastric erosions following severe scalding of th…

Neil Summerell, a 34-year-old man with intellectual disability, epilepsy, and vision/hearing impairment, died from acute gastric erosions following severe scalding injuries sustained on 29 November 1999. He was scalded t…

emergency medicinegeneral practicesystemcommunication
NThospital2003-07-17

Inquest into the death of Lennie Pinawrut

67y · Male·acute renal failure with associated severe acidosis and hyperkalemia

A 67-year-old Aboriginal male with dementia was discharged from Royal Darwin Hospital on 4 November 2001 following cystoscopy and bladder neck incision for suspected obstruction. Critical communication failures meant the…

urologysurgerycommunicationdelaygentamicine

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