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QLDcommunity2016-12-21

Capps, Ruth

75y · Female·multiple injuries due to or as a consequence of motor vehicle collision

Ruth Capps, 75, died in a motor vehicle collision after drifting into oncoming traffic. She had multiple medical conditions including diabetes, sleep apnoea, chronic back pain, osteoarthritis, and recurrent falls. Despit…

general practiceoccupational therapydiagnosticcommunicationnitrazepam
VIChospital2016-06-24

Finding into death of Graeme John Jennings

65y · Male·staphylococcal sepsis (secondary to Staphylococcus aureus infection seeding rect…

A 65-year-old man presented with quad bike accident injuries and had markedly elevated inflammatory markers (CRP 329–556, WCC 12.3–18) during his first hospital admission. These were suggestive of developing infection, p…

general surgeryemergency medicinediagnosticcommunicationindocid
QLDaged care2016-05-03

Thomas, Florence Lillian - Non-inquest findings

85y · Female·neck injury (cervical spine fracture) as a consequence of a fall

Mrs Florence Thomas, 85, died from cervical spine fractures sustained when she fell from a toilet chair at her nursing home. She had multiple documented falls and explicit care plan instructions never to be left alone on…

geriatric medicineemergency medicinesystemcommunication
VIChospital2016-03-15

Finding into death of Reginald John Brooks

99y · Male·Pneumonia

A 99-year-old man with cognitive decline sustained a hip fracture from a fall and subsequently underwent surgery with informed consent. He suffered cardiopulmonary arrest post-operatively and was resuscitated despite the…

general medicineorthopaedic surgerycommunicationsystem
VIChome2015-08-26

Finding into death of Frank Day

60y · Male·Pulmonary thromboembolism in a man with deep vein thrombosis following a fractur…

A 60-year-old man with obesity, hypertension, and dyslipidemia sustained a fractured right ankle in a motorcycle collision. He presented to ED with chest pain on 3 November but was diagnosed with musculoskeletal pain; EC…

emergency medicineorthopaedic surgerycommunicationsystemmorphine
QLDhospital2015-05-26

SM - Non-inquest findings

32y · Male·Pulmonary embolism originating from deep vein thrombosis in right calf

A 32-year-old man died from pulmonary embolism six days after emergency appendectomy for perforated appendicitis. VTE prophylaxis was appropriately prescribed. However, the clinical team failed to investigate persistent …

general surgeryanaesthesiadiagnosticcommunicationheparin
VIChospital2015-04-29

Finding into death of John Manias

63y · Male·Multisystem organ failure, pneumonitis and sepsis; complications arising from a …

A 63-year-old man died on 11 March 2008 from multisystem organ failure, sepsis and pneumonitis following a fall. He was admitted to Dandenong Hospital with rib fractures and pelvic injuries. Clinical deterioration occurr…

trauma surgeryorthopaedic surgerydiagnosticcommunicationceftriaxone
NSWhome2014-12-22

Inquest into the death of Margaret Elizabeth HILLS

60y · Female·undetermined

Margaret Elizabeth Hills, a 60-year-old woman with chronic pain and depression from a work-related spinal injury, disappeared on 2 February 2010 from her home in Katoomba, NSW. Her skeletal remains were discovered nearly…

general practicepsychiatrycommunicationdelay
WAaged care2014-07-23

Inquest into the Death of Daniel

83y · Female·Complications following fracture and surgical repair of the left hip in an elder…

Nola Inez Daniel, 83, died from complications following a hip fracture and subsequent surgery at Bunbury Regional Hospital on 7 January 2010. She sustained a fractured left neck of femur during a fall at Regis Forrest Ga…

geriatric medicineorthopaedic surgerydiagnosticcommunication
QLDhospital2014-06-20

O - Non-inquest findings

82y · Male·hypoxic-ischaemic encephalopathy due to cardiac arrest as a result of fractured …

An 82-year-old man died from hypoxic-ischaemic encephalopathy following perioperative cardiac arrest during ankle fracture surgery. The anesthetist failed to recognise clinical deterioration, did not intubate despite sig…

anaesthesiaorthopaedic surgerydiagnosticproceduralbisoprolol
VIChospital2014-05-20

Finding into death of Angela Therese Thompson

51y · Female·Aspiration pneumonia in a woman with Down syndrome and Alzheimer's dementia

Angela Thompson, a 51-year-old woman with Down syndrome and early-onset Alzheimer's dementia, died from aspiration pneumonia following a shoulder fracture. She was in DHS supported residential care when she suffered freq…

general practicepsychiatrysystemcommunicationescitalopram
VIChospital2014-04-17

Finding into death of Gail Fergusson

65y · Female·Liver failure secondary to paracetamol toxicity

A 65-year-old retired nurse died from paracetamol toxicity and liver failure after taking excessive paracetamol tablets for pain relief following a fractured arm. She presented to hospital on Saturday with a fracture. Cr…

emergency medicineendocrinologycommunicationsystemparacetamol
SAhome2014-04-17

Coroner's Finding: KEITH George

80y · Male·gunshot wound to the head

An 80-year-old man with chronic back pain died by self-inflicted gunshot wound to the head on 1 March 2011. Five days before his death, he mentioned suicide using a rifle to his long-term general practitioner, Dr Daniels…

general practiceorthopaedic surgerydiagnosticcommunicationoxycodone
SAhospital2014-02-14

Coroner's Finding: RYAN John William and WALTON Patricia Dawn

Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…

Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…

anaesthesiaorthopaedic surgerydiagnosticcommunicationmorphine
WAhospital2013-11-12

Inquest into the Death of Ford, Valma May Ruth

77y · Female·Complications following a recent fracture and surgical repair of the right hip i…

A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Ke…

orthopaedic surgeryemergency medicinediagnosticsystemwarfarin
SAhospital2013-08-15

Coroner's Finding: STOCK Anthony Douglas

64y · Male·hypoxic-ischaemic encephalopathy complicating cardiac arrest due to retroperiton…

A 64-year-old man died from hypovolaemic cardiac arrest caused by retroperitoneal bleeding from a pelvic fracture. The bleeding occurred six days post-injury while on high-dose enoxaparin (100mg twice daily) initiated un…

orthopaedic surgeryemergency medicinediagnosticcommunicationenoxaparin
WAhospital2013-02-11

Inquest into the Death of Carroll

21y · Male·Acute hypoxic ischaemic encephalopathy and pneumonia in a man with recent trauma…

Peter Martin Carroll, age 21, died on 8 June 2007 in the ICU at Royal Perth Hospital from acute hypoxic ischaemic encephalopathy and pneumonia following oxycodone overdose. He had been discharged that day (5 June) after …

emergency medicineorthopaedic surgerycommunicationsystemoxycodone
VICaged care2013

Finding into death of Moira McCarthy

85y · Female·Hypostatic bronchopneumonia complicating fractured occipital condyle and left ne…

Moira McCarthy, an 85-year-old woman with dementia and multiple comorbidities requiring high-level aged care nursing, sustained a fall on 24 April 2013 when a ceiling hoist descended unexpectedly during a patient transfe…

geriatric medicineorthopaedic surgeryproceduralcommunicationmorphine
QLDhospital2012-11-28

Hammett, Christopher

47y · Male·Aspiration pneumonia due to or as a consequence of coronary atherosclerosis

Christopher Hammett, a fit 47-year-old, died from aspiration pneumonia with contributing coronary atherosclerosis following routine L5-S1 disc replacement. A critical oxygen desaturation (64%) occurred during transfer fr…

orthopaedic surgeryanaesthesiadiagnosticcommunicationmorphine
QLDaged care2012-10-19

Anderson, Stanley Charles

86y · Male·coronary and cerebral atherosclerosis with significant conditions of fractured l…

Mr. Stanley Charles Anderson, aged 86, died at Gympie General Hospital from coronary and cerebral atherosclerosis, precipitated by injuries sustained in a fall at a nursing home. While transferring from a bath trolley to…

geriatric medicineoccupational and environmental healthsystemcommunication

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