Coronial
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NSWhospital2021-12-23

Inquest into the death of Shelley YOUNG

65y · Female·choking on a tangerine

Ms Shelley Young, a 65-year-old woman with long-standing schizoaffective disorder and multiple complications from chronic antipsychotic use including dysphagia and tardive dyskinesia, died from choking on a tangerine whi…

psychiatrygeriatric medicinecommunicationsystemclozapine
TASaged care2021-11-04

Coroner's Finding: Rosendale, Dwayne Edward

36y · Male·Complications of morbid obesity, including cardiac enlargement, aspiration of ga…

A 36-year-old man with treatment-resistant schizophrenia and Capgras syndrome died from complications of morbid obesity (183.5 kg, BMI 45.3). He was discharged from hospital on 14 January 2019 after admission for respira…

psychiatrygeneral medicinesystemdelayzuclopenthixol
NSWhospital2021-10-22

Inquest into the death of Ivan Goolagong

68y · Male·Metastatic Pancreatic Adenocarcinoma

Ivan Leo Goolagong, a 68-year-old Wiradjuri man, died of metastatic pancreatic adenocarcinoma while in Long Bay Prison Hospital Medical Subacute Unit in July 2017, five months after undergoing a Whipple procedure. The co…

oncologypalliative caresystemcommunicationamylase
NSWhospital2021-10-12

Inquest into the death of Bruce HODGES

78y · Male·cardiorespiratory failure due to complications of tracheal stenosis

Bruce Hodges, a 78-year-old man with a 20-year-old tracheostomy following laryngeal cancer surgery, presented to hospital with progressive shortness of breath and tracheal stenosis. Over 48 hours of admission, his respir…

emergency medicineENT surgerydiagnosticsystemnebulised saline
QLD2021-05-24

SVE

43y · Male·Hanging

A 43-year-old man remanded in custody for serious sexual offences against children died by hanging in an older prison cell. While he expressed fears about safety and had passive suicidal ideation months before his death,…

psychiatrypsychologysystemdelay
VIChospital2021-04-30

Finding into death of Valerie Margaret Fraser

94y · Female·Complications of metastatic lobular carcinoma of the breast in a woman with deme…

A 94-year-old woman with advanced dementia and metastatic breast cancer died from complications of her malignancy. She presented repeatedly with vomiting due to duodenal obstruction from metastatic tumour, but this was n…

general medicinegastroenterologycommunicationdiagnostictamoxifen
SAhospital2020-12-18

Coroner's Finding: WALSH Patrick Lawrence

86y · Male·combined effects of acute myeloid leukaemia, acute renal failure and staphylococ…

Patrick Lawrence Walsh, aged 86, died in custody at Royal Adelaide Hospital from combined acute myeloid leukaemia, acute renal failure, and staphylococcal pneumonia. He had a significant medical history including ischaem…

haematologyinfectious diseasesdiagnosticdelay
QLDprison2020-12-17

Hobbs, Richard William

48y · Male·Coronary atherosclerosis with acute cardiac event

Richard William Hobbs, aged 48, died from cardiac arrest in custody at Brisbane Correctional Centre on 21 November 2017. He had significant comorbidities including coronary artery disease (recent stent insertion), diabet…

emergency medicinecardiologydiagnosticcommunicationaspirin
WA2020-11-28

Inquest into the Death of Wayne Thomas LARDER

42y · Male·ligature compression of the neck (hanging)

Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental healt…

psychiatrypsychologydiagnosticsystemmethamphetamine
SAhospital2020-10-30

Coroner's Finding: VELT Hank Jakob

65y · Male·ischaemic and hypertensive heart disease with contributing acute cholecystitis (…

A 65-year-old man with hypertension presented with acute cholecystitis, underwent laparoscopic cholecystectomy, and initially recovered well. On post-operative day 7, he experienced chest pain radiating to his jaw. Two E…

general surgerycardiologydiagnosticcommunication
NSW2020-10-23

Inquest into the death of Ye Chiu

67y · Male·Head injuries sustained from a fall from the upstairs landing in Goldsmith G Blo…

Ye Chiu, a 67-year-old Chinese-speaking prisoner on remand, died by suicide in prison on 6 February 2017 after falling head-first from a landing. He had a complex psychiatric history including anxiety, depression, hypona…

psychiatryemergency medicinesystemcommunicationparoxetine
WAhospital2020-09-04

Inquest into the Death of Malakai Matiu Ward PARAONE

0y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…

Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. …

emergency medicineintensive carediagnosticcommunicationparacetamol
TAShospital2020-08-12

Coroner's Finding: Maynard, Grant Godfrey

60y · Male·multi-organ failure due to injuries sustained in motor vehicle accident, specifi…

A 60-year-old Aboriginal man with significant comorbidities (cardiomyopathy, cirrhosis, renal failure, diabetes) presented to ED following a motor vehicle accident at low speed. Despite chest imaging showing pleural effu…

emergency medicinegeneral medicinediagnosticdelaydoxycycline
TAShospital2020-08-11

Coroner's Finding: Howard, Noeline Dawn

76y · Female·pulmonary embolism due to carcinomatosis

A 76-year-old woman presented to hospital with shortness of breath and was initially diagnosed with community-acquired pneumonia and later pulmonary oedema. Both diagnoses were incorrect. She had widespread cancer (carci…

emergency medicinerespiratory medicinediagnosticdelayintravenous fluids
VIChospital2020-07-16

Finding into death of Lydia Maxfield

85y · Female·Multisystem failure complicating ischaemic heart disease and ischaemic bowel in …

Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnorm…

orthopaedic surgeryanaesthesiacommunicationsystemondansetron
VIChospital2020-07-14

Finding into death of Gerard Guy Vaz

61y · Male·Undetermined

Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuc…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
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
QLDrural hospital2020-05-08

FD - Non-inquest findings

68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…

A 68-year-old woman with oculopharyngeal muscular dystrophy died from sepsis due to peritonitis following dislodgement of a PEG tube inserted on 27 February 2018. She presented to a rural hospital 5.5 hours post-discharg…

gastroenterologyemergency medicinediagnosticcommunicationaugmentin duo
TAShospital2020-04-07

Coroner's Finding: Pettersson, Jan Axel

71y · Male·disseminated fungal (Cryptococcus) infection of the lungs, brain and meninges

A 71-year-old man presented with fever, confusion, and gait disturbance in October 2017. A lung mass was identified on chest X-ray and presumed malignant, but inflammatory markers were unremarkable. Despite clinical dete…

general medicinerespiratory medicinediagnosticdelay
WAhospital2020-04-02

Inquest into the Death of Valerie KELLY

67y · Female·bronchopneumonia and acute liver failure on a background of liver cirrhosis and …

Valerie Kelly, a 67-year-old woman with cirrhosis, hepatocellular carcinoma, and multiple comorbidities, died at Royal Perth Hospital from bronchopneumonia and acute liver failure. She was in custody at Bandyup Women's P…

hepatologygastroenterologycommunicationsystemolanzapine
134510

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