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SAhospital2018-12-06

Coroner's Finding: RUSSELL Michael John and GRAHAM Leslie Robert

Unknown·Michael Russell: intracranial haemorrhage complicating surgery for right cerebra…

Two patients died following stroke interventions on 18 April 2017 at the Royal Adelaide Hospital. Michael Russell (60) died from intracranial haemorrhage following vessel perforation during thrombectomy for acute coronar…

radiologyneurologycommunicationsystemticagrelor
TAScommunity2018-12-05

Coroner's Finding: Webb, Shanelle Jean

22y · Female·Sudden Unexpected Death in Epilepsy (SUDEP)

22-year-old woman with epilepsy, cognitive disability and schizophrenia died of Sudden Unexpected Death in Epilepsy (SUDEP) during respite care. She experienced a nocturnal seizure while sleeping at a disability support …

neurologydisability medicinesystemdelayolanzapine
NTcommunity2018-12-03

Inquest into the death of Sabrina Di Lembo

19y · Female·self-inflicted hanging

Sabrina Di Lembo, a 19-year-old law student, died by suicide after experiencing anxiety and panic attacks during exam preparation. Over nine weeks, she had 17 medical contacts but received inadequate assessment, no detai…

general practicepsychiatrydiagnosticmedicationvenlafaxine
VIC2018-11-29

Finding into death of Vicki Evelyn Webster

63y · Female·Head injuries sustained in a motor vehicle accident

Vicki Webster, a 63-year-old woman, died from head injuries sustained in a motor vehicle accident on Lake Rowan Road, Victoria. She swerved to the left to pass an oncoming vehicle, overcorrected to the right, left the ro…

systemdelay
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
VIChospital2018-11-19

Finding into death of Robert Humphreys

71y · Male·Aspiration in setting of paralytic ileus in patient in convalescent phase of abd…

A 71-year-old man died from aspiration complicating prolonged paralytic ileus on postoperative day 9 following open abdominal aortic aneurysm repair. Despite clinical signs of persistent ileus (vomiting, abdominal disten…

vascular surgeryintensive carediagnosticdelayatropine
VIChospitalPodcast2018-11-09

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
VICcommunityPodcast2018-11-09

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
VIChomePodcast2018-11-09

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
VIChospitalPodcast2018-11-09

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
VICcommunityPodcast2018-11-09

Finding into death of Omar Jamil Moujalled

18y · Male·acute asthma

Omar Jamil Moujalled, 18 years old, died from acute asthma during the unprecedented thunderstorm asthma event in Melbourne on 21 November 2016. He had pre-existing asthma and severe hay fever with exceptionally high sens…

emergency medicinerespiratory medicinesystemdelaysalbutamol
VIChomePodcast2018-11-09

Finding into death of Clarence Tuivaiese Nicholas Leo

37y · Male·Acute asthma (thunderstorm asthma event)

37-year-old male died from acute asthma during the unprecedented Melbourne thunderstorm asthma event (21-22 November 2016). He had moderate to severe asthma with suboptimal preventer medication use and recently diagnosed…

emergency medicineparamedicinedelaysalbutamol
TAShospital2018-11-08

Coroner's Finding: Fenton, Timothy John

57y · Male·sepsis and multiple organ failure secondary to aspiration pneumonia

Timothy Fenton, a 57-year-old intellectually disabled man on antiepileptic medications, developed a small bowel ileus after presenting with vomiting and diarrhoea. Following emergency laparotomy, his nasogastric tube was…

emergency medicinegeneral surgeryproceduralcommunicationsodium valproate
TAShome2018-11-05

Coroner's Finding: Unwin, David Paul

55y · Male·probable sepsis in the setting of immunosuppression, a skin wound and chronic di…

David Paul Unwin, a 55-year-old kidney transplant recipient with polycystic kidney disease, died of sepsis in January 2017. He presented with progressive symptoms including chronic diarrhoea, weight loss (16kg in 8 weeks…

nephrologygeneral practicediagnosticdelay
ACT2018-11-01

AN INQUIRY INTO THE FIRE AT THE SYDNEY BUILDING

Fire caused by unattended cooking wok on gas stove with ignited cooking oil

A fire occurred at Sydney Building, Canberra City on 17 February 2014 in the kitchen of Japanese restaurant Izakaya Coo 2 G 4 U, caused by an unattended cooking wok on a gas stove that ignited cooking oil. A staff member…

systemdelay
TASaged care2018-10-30

Coroner's Finding: Dent, Freda Lillian Florence

85y · Female·ischaemic heart disease due to stenosis of coronary bypass grafts

An 85-year-old woman with significant cardiac history (prior coronary artery bypass graft) presented with gastrointestinal symptoms. Her GP ceased rosuvastatin without direct communication to nursing staff. Care staff id…

general practicegeriatric medicinecommunicationsystemrosuvastatin
VIChospital2018-10-26

Finding into death of Baby B

1y · Male·Hypoxic-ischaemic encephalopathy and multisystem failure in the setting of extre…

Baby B was born by emergency breech extraction in an ambulance after obstructed labour, sustaining severe hypoxic-ischaemic injury. The death was multifactorial. The mother had limited antenatal care despite known metham…

obstetricsneonatologydiagnosticsystemmethamphetamine
QLDhospital2018-10-24

Statis, Joshua Ryan

12y · Male·Cardiac haemorrhage due to or as a consequence of congenital aortic stenosis (su…

Joshua Statis, a 12-year-old with complex congenital aortic stenosis, died 18 days after a redo Konno procedure and aortic valve replacement when a CardioCel patch to the right ventricular outflow tract (RVOT) ruptured, …

cardiothoracic surgerycardiologycommunicationdiagnosticwarfarin
NSWhospital2018-10-22

Inquest into the death of Sandra Cree

71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…

Sandra Cree, a 71-year-old woman, died from a ruptured abdominal aortic aneurysm (AAA) after undergoing an elective endovascular repair procedure in Brisbane. She presented to a remote hospital (Lightning Ridge Multi-Pur…

emergency medicinevascular surgerydiagnosticcommunicationgentamicin
TAScommunity2018-10-18

Coroner's Finding: MacQueen, Tyrone Frederick

25y · Male·unable to determine

Tyrone Frederick MacQueen disappeared on 1 July 1994 at age 25. He had chronic schizophrenia with poor medication compliance, recent psychiatric hospitalization, expressed suicidal ideation, self-harm (wrist cutting), de…

psychiatrygeneral practicesystemdelaysuromtil

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