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NSWhospital2022-08-17

Inquest into the death of Robert Bischard

75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…

Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…

orthopaedic surgerycardiologydiagnosticsystemfurosemide
VIChospital2022-07-28

Finding into death of H C

6y · Male·Global cerebral ischaemia secondary to perinatal asphyxia

HC was a neonate who died at 6 days old from global cerebral ischaemia secondary to perinatal asphyxia. He was born following an emergency caesarean section for obstructed labour and fetal distress. Key clinical lessons …

obstetricsneonatologydiagnosticcommunication
VIChospital2022-06-06

Finding into death of Paul Turner

73y · Male·Haemorrhagic stroke in the setting of recent inguinal hernia surgery and change …

Paul Turner, 73-year-old with atrial fibrillation and aortic valve replacement, underwent elective bilateral inguinal hernia repair in August 2018. His cardiologist advised ceasing rivaroxaban 3-4 days preoperatively; ho…

cardiologysurgerymedicationcommunicationrivaroxaban
NSWhospital2022-05-30

Inquest into the death of Alex BRAES

18y · Male·Multi organ failure due to sepsis from a Group A streptococcus infection

Alex Braes, an 18-year-old from Broken Hill NSW, died of multi-organ failure due to Group A streptococcus sepsis. He presented to Broken Hill Base Hospital three times over 24 hours with knee pain that progressed to seps…

emergency medicineinfectious diseasessystemdelayceftriaxone
VIChospital2022-05-09

Finding into death of Robert Albert Burns

75y · Male·Multiorgan dysfunction syndrome complicating anastomotic leak following hemicole…

A 75-year-old man died from multiorgan dysfunction following an anastomotic leak after hemicolectomy for caecal adenocarcinoma. Initial post-operative recovery appeared normal, but he deteriorated from day 3 onwards. The…

colorectal surgeryintensive carediagnosticdelay
SAhospital2022-04-13

Coroner's Finding: Cook, Courtney Liza

20y · Female·multi-organ failure due to polypharmacy overdose

A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where i…

emergency medicinegastroenterologydiagnosticcommunicationparacetamol
WAhospital2022-03-28

Inquest into the Death of Morgan John EDWARDS

31y · Male·Complications in association with intestinal volvulus

31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…

emergency medicinegastroenterologydiagnosticcommunication
NSWhospital2022-03-25

Inquest into the death of Anthony Barrett

54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…

Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…

orthopaedic surgeryvascular surgerycommunicationdiagnosticclopidogrel
TAShospital2022-03-21

Coroner's Finding: Mackey, Lois Winifred

83y · Female·decompensated right heart failure (cor pulmonale) immediately following mitral v…

An 83-year-old woman died from decompensated right heart failure (cor pulmonale) immediately following mitral valve replacement surgery. She had chronic pulmonary hypertension secondary to severe mitral regurgitation fro…

cardiothoracic surgerycardiologydiagnosticdelay
VIChospital2022-03-15

Finding into death of Ann Leah Jones

87y · Female·Pulmonary artery rupture complicating pulmonary artery catheter insertion in a w…

Mrs Jones, an 87-year-old woman with severe ischaemic heart disease, died from pulmonary artery rupture during elective off-pump coronary artery bypass surgery. A Swan-Ganz pulmonary artery catheter (PAC) was inserted pr…

cardiothoracic surgeryanaesthesiaproceduralsystemfentanyl
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
VIChospital2022-01-07

Finding into death of CDK

71y · Female·Complications post aortic endarterectomy

A 71-year-old woman died from complications following elective aortic endarterectomy for leg claudication. Post-operatively, she developed acute bilateral lower limb ischaemia with absent pulses, pale/mottled skin, and s…

vascular surgeryintensive carediagnosticdelayenoxaparin
VIC2021-12-17

Finding into death of KW

4y · Unknown·Drowning

A 4-year-old boy drowned in a resort pool during a family birthday party on 13 December 2020. Despite wearing a buoyancy vest initially, he removed it to use water slides more freely. While approximately 8 adults were pr…

emergency medicineanaesthesiasystemdelay
QLDhospital2021-11-01

Masoumali, Omid

24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns

Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement.…

plastic and reconstructive surgeryintensive carecommunicationsystem
VIChospital2021-10-26

Finding into death of John Francis Flynn

69y · Male·Hypoxic ischaemic brain injury secondary to right facial artery pseudoaneurysm r…

69-year-old male with tonsillar squamous cell carcinoma presenting with throat pain and trismus 12 days after completing chemoradiotherapy. On presentation to emergency department with bleeding, airway risk was under-rec…

emergency medicineENT surgerydiagnosticcommunicationparacetamol/codeine
VIChospital2021-10-25

Finding into death of MR XH

46y · Male·Hypoxic ischaemic brain injury complicating a cardiac arrest during anaesthetic …

A 46-year-old male underwent elective inguinal hernia repair at a private hospital. During anaesthetic induction, he experienced cardiac arrest. The endotracheal tube (ETT) was visualized passing through the vocal cords,…

anaesthesiaintensive carediagnosticproceduralfentanyl
WAmental health2021-10-22

Inquest into the Death of Russell David BROCKLISS

38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…

Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute car…

psychiatryemergency medicinedelaysystemrisperidone depot
VIChospital2021-09-21

Finding into death of AH

37y · Male·Mixed Drug Toxicity (Oxycodone, Quetiapine, Pregabalin and Clonazepam)

A 37-year-old man died from mixed drug toxicity (oxycodone, quetiapine, pregabalin, clonazepam) after ingesting unknown quantities of his own medications in an ED. He presented with trauma symptoms four days post-motor v…

emergency medicinetoxicologydiagnosticcommunicationoxycodone
VIChospital2021-07-20

Finding into death of Barry Brown

56y · Male·Internal blood loss, complications arising from laparoscopic cholecystectomy

Barry Brown, a 56-year-old man, died from internal bleeding after laparoscopic cholecystectomy due to critical systemic failures in post-operative care and diagnosis. Following hypotension at 7:30pm, nursing staff failed…

general surgeryintensive carediagnosticcommunicationnoradrenaline
TAShospital2021-07-02

Coroner's Finding: HB

8y · Male·acute exacerbation of chronic asthma

An 8-year-old boy with undertreated chronic asthma presented to North West Regional Hospital with acute exacerbation. Initial assessment underestimated severity. Despite initial improvement with salbutamol, ipratropium a…

paediatricsemergency medicinediagnosticcommunicationfluticasone/salmeterol

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