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WAhome2013

Inquest into the Death of Osborne, Wendy Elaine

Female·early bronchopneumonia complicating combined drug toxicity (fentanyl overdose)

Wendy Osborne, a woman with a history of substance abuse and psychiatric issues, died from bronchopneumonia complicating fentanyl overdose. Her GP prescribed fentanyl patches (50mcg/h, increased to 75mcg/h) after one wee…

general practicepharmacologymedicationcommunicationfentanyl
QLDhospital2012-12-06

McNaught, Judith

69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…

A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consul…

surgeryanaesthesiadiagnosticmedicationmorphine
SAhospital2012-11-15

Coroner's Finding: Davis Tracy-Lee

34y · Female·hypoxic ischaemic encephalopathy due to anaphylactic shock due to antibiotic all…

A 34-year-old woman died from anaphylactic shock to Ceclor, a cephalosporin antibiotic prescribed for otitis externa. Her medical records clearly documented allergies to cephalosporins (Ibilex) and sulphur-based antibiot…

general practiceemergency medicinediagnosticmedicationceclor
SAhospital2012-11-15

Coroner's Finding: Butler Mark Andrew

49y · Male·pneumonia, hypoxic brain injury and cardiac arrest

49-year-old male with chronic cannabis dependence and depression developed post-surgical delirium following emergency anterior resection for perforated diverticulum. He became acutely agitated and paranoid, was detained …

colorectal surgerypsychiatrydiagnosticmedicationfentanyl
NSW2012-09-27

Inquest into the deaths of James UNICOMBE, Michael POOLE, Grace YATES

Three deaths with different primary causes: James Unicomb - acute toxicity due t…

Combined inquest into three deaths at Psyche South Clinic involving treatment failures: James Unicomb (22, 2005) from multi-drug overdose after naltrexone implant; Michael Poole (48, 2008) from ruptured aneurysm post-Rap…

addiction medicinegeneral practicediagnosticmedicationnaltrexone
VIChospital2012-09-11

Finding into death of Robert Anderson

50y · Male·Complications of right buttock necrotising fasciitis secondary to chronic right …

50-year-old male with chronic pain from jockey injuries became dependent on morphine. General practitioner prescribed intramuscular (IM) morphine for self-administration at home from 2005–2007 at doses of 120–240mg daily…

general practicepsychiatrydiagnosticmedicationmorphine sulphate
VICaged care2012-09-10

Finding into death of Robert Edward Curry

38y · Male·End-stage respiratory failure secondary to kyphoscoliosis

Robert Edward Curry, a 38-year-old man with profound intellectual disability, cerebral palsy, severe kyphoscoliosis, and chronic respiratory compromise died from end-stage respiratory failure. A medication administration…

general practiceforensic medicinemedicationcarbamazepine
NSWcommunity2012-09-05

Inquest into the death of Lynda Vanessa CLIFFORD

29y · Female·respiratory depression as a result of the interaction of prescribed medications

A 29-year-old woman with mental illness and substance use was admitted to hospital with psychosis and suicidality. She was discharged on six CNS-depressant medications including three antipsychotics, an antidepressant, a…

psychiatrygeneral practicecommunicationsystemclozapine
VIChospital2012-08-02

Finding into death of Elsinore Mitchell

74y · Female·right lower lobe pneumonia (Staphylococcus aureus)

A 74-year-old woman admitted for depression and functional decline following aortic valve replacement received 15mg Nitrazepam instead of prescribed 15mg Mirtazapine due to drug name confusion. The sedation caused aspira…

general medicinepsychiatrymedicationcommunicationnitrazepam
WAhospital2012-06-27

Inquest into the Death of LEE

37y · Male·Respiratory arrest in association with medication drug effect and alcohol intoxi…

David James Lee, a 37-year-old Aboriginal man with schizophrenia, died on 15 July 2007 at Port Hedland Regional Hospital from respiratory arrest associated with medication effect and alcohol intoxication. He arrived at t…

emergency medicinepsychiatrymedicationcommunicationchlorpromazine
QLDhospital2012-06-22

Paton, Daniel William

45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia

A 45-year-old man died from hypoxic-ischaemic encephalopathy following cardiopulmonary arrest 11 hours after elective wrist plate removal surgery. Multiple contributing factors were identified: undisclosed obstructive sl…

anaesthesiapain medicinediagnosticmedicationmorphine
VIChome2012-05-18

Finding into death of David Andrew Trengrove

38y · Male·Toxic effects of morphine in a setting of benzodiazepine dependency

A 38-year-old man with chronic pain, mental illness, and benzodiazepine dependency died from morphine toxicity. He obtained multiple benzodiazepines and opioids from five different doctors through 'prescription shopping'…

general practicepsychiatrymedicationcommunicationmorphine
NSWaged care2012-05-11

Inquest into the deaths of Shaneen BATTS, Ilona TAKACS, Dorothy HUDSON, Ian BIRKS, Donald MacKELLAR and Mohammed RAMZAN

Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …

This inquest examined six sudden deaths of residents at 300 Hostel, Marrickville, between June 2009 and August 2010. All residents had schizophrenia on multiple antipsychotic medications and severe, untreated physical co…

psychiatrygeneral practicediagnosticmedicationolanzapine
VICaged care2012-04-30

Finding into death of Kenneth Agnew

37y · Male·combined ethanol and drug toxicity

Kenneth Agnew, a 37-year-old man resident in aged care, died from combined ethanol and drug toxicity involving methadone and benzodiazepines. He had hepatitis C and fatty liver disease. Critical clinical lessons include:…

general practicegeneral medicinediagnosticcommunicationmethadone
NThospital2012-03-28

Inquest into the death of Master F

17y · Male·pneumonia and respiratory failure associated with choreoathetoid cerebral palsy

A 17-year-old Indigenous male with severe choreoathetoid cerebral palsy, feeding difficulties, and swallowing dysfunction died of pneumonia and respiratory failure in ICU. He had missed lunch medications (Baclofen and Ga…

general surgerypaediatricsmedicationbaclofen
VIChospital2012-02-22

Finding into death of Ellen Mary OConnor

90y · Female·Renal failure secondary to gentamicin therapy for urinary tract infection (sepsi…

Ellen O'Connor, a 90-year-old woman with renal artery stenosis and coronary artery disease, died from acute renal failure following gentamicin administration for Pseudomonas aeruginosa urinary tract infection. A single 2…

orthopaedic surgeryplastic and reconstructive surgerymedicationdiagnosticgentamicin
QLDhospital2012-02-21

Vaggs, Lyji

28y · Male·hypoxic brain injury sustained during restraint in the foyer of the Acute Mental…

Lyji Vaggs, a 28-year-old Aboriginal man with schizophrenia, died from hypoxic brain injury sustained during restraint at Townsville Hospital's Acute Mental Health Unit on 13 April 2010. He had declined admission at ED o…

psychiatryemergency medicinediagnosticmedicationolanzapine
NSWhospital2011-12-21

Coroner's Finding: Gabrielle Coventry

14y · Female·Neisseria meningitidis infection (meningococcal septicaemia)

A 14-year-old girl presented to Gosford Hospital Emergency Department on 4 December 2007 with high fever (40°C), headache, vomiting, myalgia, and haemodynamic instability (hypotension, tachycardia, tachypnoea)—all signs …

emergency medicinepaediatricsdiagnosticmedicationceftriaxone
NThospital2011-09-09

Inquest into the death of Linda Nha Tran

34y · Female·Catastrophic post-partum haemorrhage following caesarean delivery, secondary to …

A 34-year-old Vietnamese woman died from catastrophic postpartum haemorrhage following an elective caesarean delivery. Placenta accreta was discovered intraoperatively and managed with blood transfusion, uterotonic agent…

obstetricsanaesthesiamedicationcommunicationoxytocin
NSWmental health2011-09-02

Ang 2011 09 21 13 31 50 906

29y · Male·acute bronchopneumonia complicated by multi-drug toxicity

Nicholas Ang, aged 29, with schizoaffective disorder, died from acute bronchopneumonia complicated by multi-drug toxicity while in a psychiatric unit. Admitted 12 August 2005, he was on clozapine, valproic acid, and clon…

psychiatrygeneral medicinemedicationcommunicationclozapine
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