Coronial
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TAShospital2016-08-26

Coroner's Finding: Brook, Jason Mark

45y · Male·massive pulmonary embolism due to deep vein thrombosis of the left leg

A 45-year-old man died of massive pulmonary embolism secondary to deep vein thrombosis, 15 days after a motorcycle injury in Thailand requiring surgical wound management and foot fracture immobilization. He was discharge…

orthopaedic surgerygeneral surgerymedicationcommunicationenoxaparin
QLDhome2016-08-22

SJM - Non-inquest findings

57y · Male·Mixed drug toxicity, predominantly propoxyphene (Doloxene)

A 57-year-old man died from mixed drug toxicity, predominantly propoxyphene (Doloxene), combined with benzodiazepines. His GP of 13 years prescribed Doloxene for 10 years despite documented alcohol abuse history, which w…

general practicepathologymedicationdiagnosticpropoxyphene
TAShospital2016-08-08

Coroner's Finding: Teressa Beswick

45y · Female·Combined effects of widely metastatic (end-stage) carcinoma of the cervix and br…

Teressa Maree Beswick, a 45-year-old woman with end-stage metastatic cervical cancer, died from the combined effects of her cancer and bronchopneumonia accelerated by a critical medication error. On 23 October 2014, she …

emergency medicinegeneral practicemedicationproceduralmorphine
NSW2016-07-15

Inquest into the death of Sheila Drysdale

75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …

A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…

plastic and reconstructive surgerygeriatric medicinemedicationproceduralaspirin
QLD2016-07-06

Mickelo, Garnett Allan

48y · Male·myocardial infarction due to coronary atherosclerosis (medically treated)

Garnett Mickelo, aged 48, died from myocardial infarction due to coronary atherosclerosis while in custody at Woodford Correctional Centre on 24 November 2012, shortly after discharge from Princess Alexandra Hospital fol…

cardiologycardiothoracic surgerymedicationcommunicationisosorbide mononitrate
VICcommunity2016-06-01

Finding into death of Benjamin Albert Appelman

30y · Male·Mixed drug toxicity (methadone, amitriptyline, alprazolam, diazepam, oxazepam, n…

Benjamin Appelman, 30, died from mixed drug toxicity in a creek in December 2010. He had engaged in prescription shopping across multiple GPs and pharmacies to obtain benzodiazepines, obtaining 1050 alprazolam, 1540 diaz…

general practicetoxicologydiagnosticmedicationmethadone
VIChospital2016-05-26

Finding into death of Delta Diawo Poke

42y · Female·Global cerebral ischaemia in a setting of anaesthesia

A 42-year-old woman died from global cerebral ischaemia following cardiac arrest during anaesthesia for a late-term termination of pregnancy. The anaesthetist, Dr McAllister, failed to obtain or ensure a functioning puls…

anaesthesiaobstetricsdiagnosticmedicationpropofol
TAScommunity2016-05-25

Coroner's Finding: Barnes, Deearne Joan

53y · Female·mixed prescription drug toxicity

Deearne Joan Barnes, a 53-year-old woman with complex psychiatric history including depression, OCD, substance abuse disorder, and chronic non-cancer pain, died from mixed prescription drug toxicity involving venlafaxine…

psychiatrypain medicinediagnosticmedicationvenlafaxine
VICmental health2016-04-20

Finding into death of Chris Pravin Prasad

51y · Male·undetermined natural causes

Chris Prasad, a 51-year-old involuntary psychiatric inpatient with schizoaffective disorder, diabetes type 2, hypertension, and obesity (BMI 30.8), was granted day leave on 17 January 2013 during extreme heat (38°C) at C…

psychiatrygeneral medicinemedicationdiagnosticpaliperidone
SAhospital2016-04-11

Coroner's Finding: OSANG Roswitha Maria

66y · Female·Cardiac failure due to atherosclerotic and hypertensive heart disease

A 66-year-old woman died from cardiac failure due to atherosclerotic and hypertensive heart disease. She presented to a rural GP with ankle oedema, cough, and palpitations during interstate travel. The GP diagnosed mild …

general practicecardiologydiagnosticmedicationsotalol
VIChome2016-04-04

Finding into death of Frank Edward Frood

47y · Male·Bronchopneumonia on a background of methadone and benzodiazepine use

Frank Frood, a 47-year-old man with a 20-year history of heroin use and opioid replacement therapy (ORT) on methadone, died from bronchopneumonia with a background of methadone and benzodiazepine use. He suffered chronic…

general practiceaddiction medicinemedicationsystemmethadone
QLDhospital2016-02-29

Mr B - Non-inquest findings

84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…

An 84-year-old man with multiple comorbidities was prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed,…

cardiologyhaematologymedicationcommunicationrivaroxaban
NSWcommunity2016-01-29

Jimmy JAMES - Findings

44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)

Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…

emergency medicineintensive carediagnosticmedicationceftriaxone
ACThospitalPodcast2015-12-18

AN INQUEST INTO THE DEATH OF CORRINA ANNE MEDWAY

32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin

A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…

obstetricsgeneral medicinediagnosticmedicationlabetalol
VIChospital2015-12-10

Finding into death of Dane Alexander Hortle

2y · Male·Tramadol toxicity in the setting of adenotonsillectomy in a child with Pierre Ro…

Dane Hortle, a 2-year-old with Pierre Robin Sequence and obstructive sleep apnoea, died from tramadol toxicity following adenotonsillectomy. He was discharged with a prescription for tramadol 25mg, which was dispensed as…

ENT surgerypaediatric surgerymedicationcommunicationtramadol
VIChospital2015-11-30

Finding into death of Maria Dolores Coliero

69y · Female·Inadvertent intravenous administration of oral ciprofloxacin in the setting of a…

A 69-year-old woman with stroke, diabetes, atrial fibrillation and osteomyelitis died from inadvertent intravenous administration of crushed oral ciprofloxacin. The antibiotic was prescribed for the nasogastric tube but …

intensive careinfectious diseasesmedicationproceduralciprofloxacin
TASaged care2015-11-12

Coroner's Finding: Henri, Paul Lucien

78y · Male·Cerebral infarction and hypoxic brain damage due to the combined effects of isch…

Paul Henri, 78, died from cerebral infarction and hypoxic brain damage following aspiration pneumonia and opioid-related complications. He was admitted to an aged care home and commenced on MS Contin (morphine) 30mg dail…

general practiceneurologymedicationdiagnosticmorphine
NSWhospital2015-10-28

Inquest into the death of Michael NELSON

62y · Male·multiple co-morbidities including dementia, Parkinson's disease, undernourishmen…

Michael Nelson, 62, died at Westmead Hospital on 3 May 2014 with multiple comorbidities including early-onset dementia, Parkinson's disease, neck dystonia (torticollis), and undernourishment. He presented to ED with inab…

emergency medicineneurologymedicationcommunicationmidazolam
NSWhome2015-10-23

Inquest into the death of Christine Drinnan

45y · Female·Multi-drug toxicity

Christine Drinnan, aged 45, died from multi-drug toxicity involving lethal morphine levels combined with pethidine, quetiapine, benzodiazepines and alcohol. Over 12 years, her GP Dr H. prescribed dangerous quantities of …

general practicepsychiatrydiagnosticmedicationmorphine
TAShospital2015-09-07

Coroner's Finding: Weir, Mary

80y · Female·subdural haematoma due to closed head injury sustained in a fall from bed in hos…

An 80-year-old woman with chronic heart failure admitted to hospital fell from bed and hit her head. Although nursing staff were concerned about a possible head injury, the House Medical Officer incorrectly concluded no …

emergency medicinegeneral medicinediagnosticmedicationaspirin
19101117

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