327 results
35y · Male·Unascertained, following autopsy. Likely drowning but circumstances undetermined…
A 35-year-old man with chronic alcohol dependence was admitted to the ED with acute alcohol withdrawal and auditory hallucinations. Despite presenting with objective signs of withdrawal (tremor, elevated BP, tachycardia,…
39y · Male·combined drug toxicity
Phillip Buckley, 39, died from combined drug toxicity involving oxycontin, diazepam, alcohol and venlafaxine. He had been prescribed high-dose oxycontin (40-80mg daily) and diazepam by his GP Dr C. for 12 years without c…
56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…
69y · Male·Intracerebral haemorrhage due to sepsis (Staphylococcus aureus bacteraemia), com…
A 69-year-old man with a history of myocardial infarction and atrial fibrillation presented to a rural hospital with fever, lethargy, tachycardia and elevated troponin. The treating doctor diagnosed NSTEMI based on the e…
32y · Male·Mixed drug toxicity (codeine, methadone, alprazolam, diazepam) in a man with cor…
James Dougan, 32-year-old man with longstanding polysubstance abuse, died from mixed drug toxicity (codeine, methadone, alprazolam, diazepam) complicated by severe coronary artery atherosclerosis. He engaged in prescript…
0y · Female·Congenital Streptococcus agalactiae (Group B) pneumonia in the setting of compli…
Baby Mabel Windmill was born in a moribund state following emergency caesarean section after complicated labour and died from congenital Group B streptococcal pneumonia. The inquest identified several suboptimal clinical…
41y · Male·Myocardial infarction secondary to coronary atherosclerosis, resulting in sudden…
A 41-year-old man with multiple cardiac risk factors (hypertension, hyperlipidemia, obesity, obstructive sleep apnoea, family history) presented with chest pain and was diagnosed with acute coronary syndrome. Coronary an…
44y · Female·Unascertained
A 44-year-old woman with chronic pain, epilepsy, and opioid dependence died at home with an unascertained cause in the setting of prescription medication use. She was a known 'doctor shopper' who obtained opioids from mu…
0y · Female·Morphine toxicity
Tamiya Calais Lievesley, a six-month-old infant, died from morphine toxicity on 2 March 2004. She ingested a fatal dose of morphine, likely administered by one of her parents who were both morphine-dependent. The coroner…
35y · Male·serotonin syndrome
Nicholas Moorby, a 35-year-old male, was found deceased at home in Lynbrook, Victoria on 11 April 2013, having last been seen alive on 9 April 2013. The coroner determined he died from serotonin syndrome. Moorby was pres…
48y · Male·Mixed prescription drug and ethanol toxicity (promethazine, citalopram and ethan…
A 48-year-old male died from mixed prescription drug and ethanol toxicity after consuming an entire packet of promethazine tablets (approximately 80mg) while significantly intoxicated following a day of heavy alcohol con…
29y · Male·Combined methadone, diazepam and clonazepam toxicity in a man commencing a metha…
Phillip Black, age 29, died from combined methadone, diazepam and clonazepam toxicity after commencing methadone maintenance therapy. He presented to Dr D. on 23 September 2010 seeking to re-commence MMT, having previous…
45y · Female·terminal epileptic seizure
Annalies Malm, a 45-year-old woman with cerebral palsy, severe intellectual disability, and epilepsy, died from a terminal epileptic seizure with aspiration pneumonia. She received incorrect medication on 7 May 2012 by a…
48y · Male·Haemophilus influenzae bronchopneumonia in the setting of alcohol and methadone …
Peter Oelfke, a 48-year-old man with alcohol and opioid dependence, died from haemophilus influenzae bronchopneumonia complicated by alcohol and methadone toxicity. He had no fixed address and lived in a tent. His GP pre…
86y · Male·Acute on chronic renal failure secondary to rhabdomyolysis as a consequence of d…
An 86-year-old man with chronic renal impairment (eGFR 37) died from acute-on-chronic renal failure secondary to rhabdomyolysis caused by a contraindicated drug interaction. His GP prescribed clarithromycin for a chest i…
22y · Male·mixed drug toxicity due to methadone, codeine, and morphine (metabolite), compou…
William Wallrock, 22, died from mixed drug toxicity four days after wisdom tooth extraction. He was initially appropriately advised to use paracetamol and ibuprofen. When inadequate pain relief prompted him to seek furth…
84y · Female·allergic reaction to metoclopramide (Maxalon) in a woman with acute myocardial i…
An 84-year-old woman with acute myocardial infarction (AMI) and ischaemic bowel died following an allergic reaction to intramuscular metoclopramide (Maxalon) administered by nursing staff without a doctor's order, despit…
66y · Male·multiple organ failure associated with the combined effects of complications of …
Daniel Lahengking, a 66-year-old Indonesian visiting family in Esperance, was diagnosed with rheumatoid arthritis by locum GP Dr H. and prescribed methotrexate 5-10mg daily, a grossly excessive dose (normal: 7.5-20mg wee…
42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…
Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…
Christopher Salib: ischaemic heart disease with multiple prescription drug toxic…
This landmark inquest examined three deaths involving prescription drug toxicity: Christopher Salib (24, ischaemic heart disease with drug toxicity), Nathan Attard (34, multi-drug toxicity), and Shamsad Akhtar (35, multi…
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