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VIChospital2020-05-12

Finding into death of Richard Mark Ray

49y · Male·Complications of Influenza A infection

Richard Mark Ray, a 49-year-old prisoner, died from complications of Influenza A infection after deteriorating rapidly from initial viral symptoms. He presented on 18 March 2019 with fever, body aches and cough, treated …

infectious diseasesintensive caredelayparacetamol
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
NSWhospital2019-12-13

Inquest into the death of Lorraine BARNES

85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…

Lorraine Barnes, an 85-year-old woman admitted to Wollongong Private Hospital for convalescence, died from sepsis with aspiration pneumonitis following iatrogenic lung injury. She developed severe malnutrition and electr…

general medicinerespiratory medicinediagnosticsystemciprofloxacin
NSWhospital2019-11-21

Inquest into the death of Ross MARTIN

56y · Male·acute pentobarbitone toxicity

Ross Martin, a 56-year-old man with a long history of depression, died from acute pentobarbitone (Nembutal) toxicity obtained online, combined with toxic levels of zopiclone, less than two weeks after premature discharge…

psychiatrygeneral practicediagnosticcommunicationpentobarbitone
WAhospital2019-07-09

Inquest into the Death of Troy Michael CONLEY

45y · Male·severe chronic obstructive pulmonary disease

Troy Michael Conley, aged 45, died from severe chronic obstructive pulmonary disease (COPD) while imprisoned. He had developed progressive lung disease from occupational exposure to gyprock dust, intravenous drug use (ta…

respiratory medicinegeneral medicinedelaymethadone
VIC2019-07-05

Finding into death of Hizir Ferman

35y · Male·Cardiorespiratory arrest in the setting of acute agitation and physical and chem…

Hizir Ferman, aged 35, died at Middleton Prison following forcible extraction from his room by SESG officers using CS gas and physical restraint. He was held prone with hands cuffed behind him, a shield on his back, and …

correctional healthemergency medicinecommunicationsystem
WAhospital2019-05-31

Inquest into the Death of Aurelio Monterlegre CRUZ

80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…

Aurelio Monterlegre Cruz, an 80-year-old man with complex medical conditions including chronic renal failure, ischaemic heart disease, diabetes, and COPD, died of bronchopneumonia complicating terminal palliative care wh…

nephrologypalliative carecommunicationdelayinsulin
WAmental health2019-05-22

Inquest into the Death of Christopher John DEBNAM

40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…

Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensat…

psychiatryrespiratory medicinediagnosticcommunicationhaloperidol
WAmental health2019-05-22

Inquest into the Death of Pamela Edith ASHLEY

64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…

A 64-year-old woman with bipolar disorder, severe obstructive sleep apnoea, obesity and diabetes presented with acute psychotic relapse following stress and sleep deprivation. Initially admitted to ED where she was sedat…

psychiatryemergency medicinecommunicationsystemchlorpromazine
VIChospital2019-03-19

Finding into death of John Edwin Wilks

76y · Male·Bronchopneumonia complicating fractured ribs sustained in a fall on a bus

John Wilks, a 76-year-old wheelchair user, fell when his wheelchair tilted during a left-turn on a bus on 13 August 2017. He sustained fractured ribs and a small haemothorax. Although initially treated with painkillers, …

intensive carerespiratory medicinesystemdelay
WAhospital2019-03-08

Inquest into the Death of Seanpol Martin Padraig O'NEILL

30y · Male·methadone toxicity

A 30-year-old man with schizoaffective disorder, narcolepsy, and obesity died from methadone toxicity while an involuntary psychiatric patient. He was prescribed multiple sedating medications including methadone, benzodi…

psychiatryemergency medicinecommunicationsystemmethadone
VIChospital2019-03-01

Finding into death of Madeleine Therese Sobb

25y · Female·Airway obstruction complicating laryngeal dilation for the treatment of subglott…

Ms Sobb, a 25-year-old woman with spondylo-epi-metaphyseal dysplasia causing severe airway abnormalities and subglottic stenosis, died from airway obstruction following laryngeal dilation. She was admitted to ICU with as…

intensive careemergency medicinecommunicationsystemadrenaline
TASmental health2019-01-04

Coroner's Finding: Roberts, Nigel Douglas

55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…

Nigel Douglas Roberts, a 55-year-old man with chronic schizophrenia, COPD, and cardiomyopathy, died from cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and olanzapine) in the presence of adv…

psychiatryemergency medicinemedicationdiagnosticclozapine
ACThome2018-12-20

Inquest into the death of Lesley Kaye Hasleby

61y · Female·respiratory failure consistent with end-stage chronic obstructive airways disord…

A 61-year-old woman with chronic obstructive airways disease, liver disease, depression, and alcohol dependence died from respiratory failure. Her general practitioner prescribed a contraindicated combination of central …

general practicerespiratory medicinediagnosticcommunicationdosulepin
VICcommunity2018-12-18

Finding into death of LF M

52y · Male·Multiple injuries sustained in a motor vehicle incident (driver) in a man with a…

A 52-year-old man with epilepsy died in a motor vehicle collision when his car struck a parked truck at high speed with no evidence of braking. Witness accounts and collision reconstruction suggested he experienced a sei…

neurologycardiologycommunicationsystemtopiramate
NSWhospital2018-11-23

BURTON-HO Anqelique File 2015-235464 Findings given by Mag Grahame DSC on 23-11-2018

12y · Female·Cardio-respiratory failure due to aspiration pneumonia

Angelique Burton-Ho, age 12, with VACTERL syndrome and difficult airway, presented to Bowral Hospital ED on 9 August 2015 with respiratory symptoms. She was inadequately triaged initially, then readmitted that evening wi…

anaesthesiaemergency medicinediagnosticdelay
VICcommunity2018-11-09

Finding into death of Apollo George Papadopoulos

35y · Male·Acute asthma

Apollo George Papadopoulos, age 35, died from acute asthma during the Melbourne thunderstorm asthma event on 21 November 2016. He had known asthma and hay fever triggered by seasonal environmental factors, was highly sen…

respiratory medicineallergy and immunologysystemdelaysalbutamol
VIChome2018-11-09

Finding into death of Le Hue Huynh

46y · Female·hypoxic ischaemic encephalopathy complicating cardiorespiratory arrest in the se…

Mrs Le Hue Huynh, 46, died from hypoxic ischaemic encephalopathy complicating cardiorespiratory arrest during the November 21, 2016 Thunderstorm Asthma event in Melbourne. She had known asthma with poor medication compli…

emergency medicineintensive caresystemdelaysalbutamol
VIChospital2018-11-09

Finding into death of Hoi-Sam Lau

49y · Male·acute asthma leading to hypoxic brain injury

Hoi-Sam Lau, 49, died from acute asthma leading to hypoxic brain injury during the unprecedented Melbourne thunderstorm asthma event of 21 November 2016. He had well-controlled asthma triggered by pollen and respiratory …

emergency medicineintensive caresystemdelaysalbutamol
VIChospital2018-11-09

Finding into death of Min Guo

29y · Male·acute asthma

A 29-year-old male with known asthma and hay fever died from acute asthma during the November 2016 thunderstorm asthma event in Melbourne. He presented to Ballarat Hospital on 21 November with severe asthma, was treated …

emergency medicinerespiratory medicinediagnosticdelaysalbutamol

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