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NSWprison2017-03-31

Inquest into the death of Keith HOWLETT

49y · Male·complications of non-small cell carcinoma of the lung

Keith Howlett, 49 years old, died from complications of non-small cell carcinoma of the lung while in custody at Junee Correctional Centre after 5 weeks of incarceration. He had complex medical needs including HIV, perip…

general practiceoncologydiagnosticsystem
WAhospital2016-12-16

Inquest into the Death of Ms DHU

22y · Female·staphylococcal septicaemia and pneumonia complicating osteomyelitis of a right 1…

Julieka Dhu, a 22-year-old Aboriginal woman, died on 4 August 2014 from staphylococcal septicaemia and pneumonia complicating osteomyelitis of a rib fracture sustained in April 2014. She was detained in police custody on…

emergency medicineinfectious diseasesdiagnosticcommunicationamphetamine
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
WAhospital2016-05-20

Inquest into the death of Sebastian Keith PARMAN

6y · Male·pneumonia complicating influenza A (H1N1) infection with secondary streptococcal…

Sebastian Parman, a 6-year-old boy, died from pneumonia complicating influenza H1N1 with secondary group A streptococcal infection causing scarlet fever, empyema and sepsis. Multiple clinical failures contributed: an inf…

emergency medicinepaediatricsdiagnosticcommunicationpenicillin
QLDhospital2016-05-06

Sweet, Lilli

6y · Female·Brain stem herniation due to pneumococcal meningitis

Lilli Sweet, a 6-year-old asplenic child with hereditary spherocytosis, died from pneumococcal meningitis with brain stem herniation. She presented to Nambour Hospital ED with vomiting, diarrhea, and headache on 25 Augus…

paediatricsemergency medicinediagnosticcommunicationparacetamol
VIChospital2016-02-17

Finding into death of Geoffrey Power

54y · Male·Complications of cervical spinal stenosis treated with cervical laminectomy and …

Geoffrey Power, aged 54, with severe intellectual disability, blindness, and perinatal hypoxic-ischemic brain injury, underwent indicated cervical laminectomy and fusion for cervical stenosis. Post-operatively, he self-r…

neurosurgeryintensive carecommunicationantibiotics
NSWcommunity2016-01-29

Jimmy JAMES - Findings

44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)

Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…

emergency medicineintensive carediagnosticmedicationceftriaxone
NSWhospital2015-08-17

Inquest into the death of Manjit SINGH

33y · Male·hypoxic respiratory failure following right pneumonectomy for treatment of sever…

Manjit Singh, a 33-year-old Indian 457 visa worker, died from hypoxic respiratory failure following a pneumonectomy for treatment of severe pulmonary tuberculosis. He had latent TB identified pre-arrival in India. Critic…

respiratory medicinecardiothoracic surgerydiagnosticcommunicationtuberculosis medications
WAcommunity2014-12-17

Inquest into the Death of BC (Subject to Suppression Order)

0y · Male·Acute meningitis due to Streptococcus pneumoniae infection, with contributory sp…

A 5-month-old Aboriginal boy with an undiagnosed splenic condition was discharged from Princess Margaret Hospital on antibiotics with a critical follow-up appointment scheduled for 11 June 2010. PMH's discharge letter, v…

paediatricsinfectious diseasescommunicationsystemantibiotics
QLDhospital2014-12-08

Gulliver, Graeme Barry; Harrison, Joanne Lee; Morten, Aileen Margaret

21y · Male·Sepsis caused by Leptospirosis (Graeme Gulliver); Group A streptococcal meningit…

Three young patients died from severe bacterial infections at rural Queensland hospitals (Mossman and Atherton). All three received delayed diagnoses and treatment. The first patient (21-year-old with leptospirosis) pres…

emergency medicineinfectious diseasesdiagnosticsystem
VIChospital2014-12-04

Finding into death of Leroy William Scott

1y · Male·Staphylococcus aureus septicaemia of unknown origin

Leroy William Scott, a 15-month-old boy, presented to Geelong Hospital with fever, lethargy, and poor oral intake. He was triaged as semi-urgent and not seen by a doctor until 5 AM, 8 hours later. Blood cultures drawn at…

paediatricsemergency medicinediagnosticcommunicationparacetamol
VIChospital2014-11-26

Finding into death of Ming Shan Yuan

88y · Male·Tuberculous pneumonia in the setting of multiple rib fractures, osteoporosis and…

Ming Shan Yuan, an 88-year-old man with osteoporosis and cachexia, died from tuberculosis pneumonia precipitated by multiple rib fractures. He suffered elder abuse and neglect by his primary carer daughter over months be…

emergency medicinegeriatric medicinediagnosticdelayantibiotics
TAShospital2014-09-19

Coroner's Finding: Tetley, Barry Lindsay

72y · Male·sepsis of undetermined source (pneumonia or spinal epidural abscess)

A 72-year-old man presented to ED with back pain, fever, elevated inflammatory markers (CRP 77.9, high WBC), hypotension (98/59 mmHg at 6:30am), hyponatremia, and hypoalbuminemia—all consistent with sepsis. Despite these…

emergency medicineintensive carediagnosticcommunication
QLDhospital2014-09-03

A Patient - Non-inquest findings

66y · Male·legionella pneumophila pneumonia

A 66-year-old man with multiple myeloma undergoing chemotherapy died from legionella pneumonia acquired from the Wesley Hospital water system. He was immunocompromised due to chemotherapy and corticosteroids, making him …

infectious diseasesoncologysystemcommunicationchemotherapy
NTcommunity2014-09-01

Inquest into the death of Braydon Brown

17y · Male·bacterial meningitis

A 17-year-old Aboriginal student died from bacterial meningitis after three clinic presentations in Yuendumu over four days. The critical failure occurred on 1 April when fever (38.3°C), persistent headache, and positive…

general practiceemergency medicinediagnosticcommunicationdiazepam
NSWhospital2014-05-09

Inquest into the death of Tama GALIERE

0y · Unknown·focal ventricular myocarditis and myonecrosis resulting from migration of a Peri…

A 10-month-old boy died from myocarditis and myonecrosis caused by migration of a PICC line into his right ventricle. The line was inserted appropriately under general anaesthetic for IV antibiotics treating periorbital …

paediatricsanaesthesiaproceduralcommunication
WAprison- 31 January 2014

Inquest into the Death of Amy TINKER

33y · Female·multiple organ failure complicating sepsis in a woman with cirrhosis of the live…

Amy Tinker, a 33-year-old Aboriginal woman with unrecognised cirrhosis from chronic alcohol abuse, died from sepsis-related multi-organ failure while imprisoned. She had been admitted to Royal Perth Hospital in 2004 with…

general practicehepatologycommunicationsystem
WAhospital2013-11-28

Inquest into the Death of Scafidas, Allegra Amelie

0y · Female·Pneumococcal meningitis

Allegra, aged 6 months, died of pneumococcal meningitis after a Healthdirect telephone triage call on 28 April 2010 that resulted in inappropriate home-care advice. She presented with fever (38.9°C), shallow rapid breath…

paediatricsinfectious diseasesdiagnosticsystemparacetamol
NT2013-11-20

Inquest into the death of Sara Lorraine Hampel

21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…

Sara Hampel, 21 years old, died from sepsis caused by necrotising fasciitis (Group A Streptococcus) on 14 October 2011, presenting 8 days post-partum with severe leg pain and multiple signs of sepsis. Critical failures i…

obstetricsemergency medicinediagnosticcommunicationparacetamol
VICcommunity2013-07-04

Finding into death of Rhys Andrew Rodger

16y · Male·Bacterial meningitis

A 16-year-old previously healthy boy died from bacterial meningitis after being misdiagnosed with gastroenteritis at a general practice. He presented with a 3-day history of vomiting, severe headache, and fever. The GP r…

general practiceinfectious diseasesdiagnosticcommunicationparacetamol

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