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QLDhospital2009-08-13

Duggan, David John

60y · Male·Hypertensive heart disease with chronic fatty liver as other significant conditi…

David Duggan, a 60-year-old man with hypertensive heart disease and cardiomegaly, was admitted to Caloundra Hospital on 10 January 2007 for management of severe acute back pain caused by a suspected L3/4 disc herniation …

emergency medicinegeneral medicinesystemcommunicationoxycodone
SAhospital2009-07-30

Coroner's Finding: BRUNT Sidney

65y · Male·acute right subdural haematoma

Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…

general practiceemergency medicinemedicationcommunicationwarfarin
WAhospital2009-02-01

Inquest into the Death of Fox

62y · Male·Acute Gastrointestinal Haemorrhage in association with Acute on Chronic Peptic U…

Kenneth Charles Fox, 62, presented to Fremantle Hospital ED on 12 April 2006 with a gastrointestinal bleed after fainting. He was diagnosed with a massive bleed causing hypovolaemic shock and stabilized with fluid resusc…

emergency medicinegeneral surgerydiagnosticdelayaspirin
SAhospital2008-08-15

Coroner's Finding: EDWARDS Natasha Anne

31y · Female·right cerebellar cerebrovascular accident (cerebellar infarction with obstructiv…

31-year-old woman presented with acute onset headache, dizziness, vomiting, facial numbness and speech difficulties. Initial CT brain showed equivocal left temporal hypodensity. Dr B. diagnosed acute migraine/benign posi…

neurologygeneral medicinediagnosticdelaymetoclopramide
WAhospital2008-07-28

Inquest into the Death of kidner

41y · Male·Head Injury in a Man with Acute Alcohol Intoxication; basal skull fracture with …

Ronald Gregory Kidner, 41, died from a basal skull fracture and severe head trauma on 25 October 2004, four days after falling at a recreation club while acutely intoxicated. He presented to Nickol Bay Hospital with sign…

emergency medicinegeneral medicinediagnosticcommunicationalcohol
WAcommunity2008-02-25

Inquest into the Death of Kimberley Coronial Report

Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…

This coronial inquiry examined 22 deaths of Aboriginal people in the Kimberley region of Western Australia between 2000 and 2007. Seventeen were self-harm deaths, with four additional accidental deaths and one homicide. …

public healthpsychiatrysystemdelayalcohol
QLD2007-11-28

Tanner, Marjorie Joyce

Female·Coronary atherosclerosis with ischaemic small bowel and Alzheimer's disease

Marjorie Joyce Tanner, an elderly woman with Alzheimer's disease, presented to Maryborough Hospital with a three-day history of abdominal pain, distension, and vomiting. Initially diagnosed with simple constipation and t…

general medicinesurgerydiagnosticsystemmetoclopramide
QLDhospital2007-11-23

Bodell, Margaret Florence Anne

65y · Female·gastrointestinal haemorrhage from duodenal ulcer

Margaret Bodell, 65-year-old with severe COAD and emphysema, was admitted with respiratory failure and developed a duodenal ulcer bleeding during hospitalisation. Critical clinical lessons include: (1) careful oxygen man…

respiratory medicinegeneral medicinecommunicationsystemprednisone
QLDhospital2006-07-28

Zimitat, Vivian Bexley

68y · Male·pulmonary embolism secondary to immobilisation as a result of subdural haemorrha…

A 68-year-old man with cardiac history presented to Rockhampton Hospital after a fall with head trauma, found unconscious with alcohol intoxication. CT scanning revealed a right subdural haematoma and skull fracture. Con…

neurosurgeryneurologycommunicationsystem
SAhospital2006-07-17

Coroner's Finding: HERBERT Raelene Vicki

29y · Female·respiratory depression caused by morphine intoxication on a background of upper …

A 29-year-old woman with infectious mononucleosis and severe sore throat died from respiratory depression caused by morphine intoxication with concurrent upper airway narrowing. A GP administered 30mg intramuscular morph…

general practiceemergency medicinemedicationdiagnosticmorphine
WAhospital2006-05-31

Inquest into the Death of nilon

67y · Female·Pneumonia (streptococcus pneumoniae) in a woman receiving treatment for carcinom…

Peggy Anne Nilon, 67, died from pneumonia (streptococcus pneumoniae) at St John of God Hospital Bunbury on 25 February 2003. Her small cell lung cancer had achieved remission following chemotherapy and radiotherapy. A cr…

oncologygeneral practicediagnosticcommunicationcisplatin
SAhospital2006-05-19

Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…

77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural ta…

cardiologycardiothoracic surgerydiagnosticproceduralramipril
SAhospital2006-01-25

Coroner's Finding: RAPHAEL Glenn Howard

74y · Male·cardiac and renal failure complicating treatment of infected ischaemic toes resu…

Glenn Howard Raphael, 74-year-old admitted for infected ischaemic toe secondary to diabetes mellitus. During his 17-day hospital stay, he developed acute renal failure leading to cardiac arrest and death. Critical failur…

vascular surgerygeneral medicinemedicationcommunicationgentamicin
WAhospital2005-11-25

Inquest into the Death of Waretini

46y · Male·Upper airway obstruction due to acute tonsillitis with laryngeal oedema and haem…

A 46-year-old man with acute tonsillitis complicated by upper airway obstruction died at Cunderdin District Hospital. He presented with severe pharyngitis on 5 September 2002, was admitted to Kellerberrin Memorial Hospit…

general practiceemergency medicinecommunicationsystempenicillin
WAhospital2005-09

Inquest into the Death of Maria Donatelli

72y · Female·Peritonitis due to perforated diverticulum in transverse colon

Maria Donatelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially managed conservatively with a provisional diagnosis of pancreatitis…

general surgeryemergency medicinediagnosticcommunicationtramadol
SAhospital2005-08-30

Coroner's Finding: O'BRIEN Barbara Ann

57y · Female·right bronchopneumonia following hypoxic brain damage secondary to cardiac arres…

A 57-year-old woman with chronic schizophrenia and non-insulin dependent diabetes was admitted to a psychiatric ward after detention under the Mental Health Act. She was found in cardiac arrest on 8 December 2001 and suf…

psychiatryemergency medicinediagnosticcommunicationclozapine
SAhospital2005-06-02

Coroner's Finding: GREEN Marie

64y · Female·Respiratory arrest secondary to morphine overdosage on a background of mild to m…

A 64-year-old woman died from respiratory arrest secondary to morphine overdose after ingesting 17 tablets of slow-release morphine (Kapanol) and diazepam. Initial emergency assessment by an intern was appropriate, but c…

emergency medicinegeneral medicinecommunicationdiagnosticmorphine
WAhospital2005-03-03

Inquest into the Death of Giovanni Bertoncini

72y · Male·acute gangrene of colon with probable perforation along with bowel obstruction a…

Giovanni Bertoncini, a 72-year-old man with diabetes and cardiac disease, presented to Sir Charles Gairdner Hospital on Christmas Day 2002 with acute abdominal pain and vomiting. Over two days, his condition deteriorated…

emergency medicinegeneral medicinediagnosticdelayparacetamol
WA2005-01-14

Inquest into the Death of Hendrik Jan Groothedde

39y · Male·Ligature compression of the neck (hanging)

Hendrik Jan Groothedde, a 39-year-old remand prisoner at Hakea Prison, died by ligature compression of the neck (hanging) on 31 January 2003. He had been admitted to custody in December 2002 following stabbing an ex-girl…

psychiatrycorrectional healthcommunicationsystemantidepressants
WAhospital2004-08-16

Inquest into the Death of Gregory Andrew Furniss

25y · Male·cerebral craniopharyngioma

Gregory Andrew Furniss, a 25-year-old male with a history of asthma and congenital cataracts, presented to Swan District Hospital on 11 August 2002 with a persistent headache. He was seen by Dr H. (registrar) who diagnos…

emergency medicinegeneral practicediagnosticdelayterbutaline

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