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NSWhome2018-02-23

Inquest into the death of Yongxing Wang

79y · Male·hypoxic brain injury due to cardio-respiratory arrest caused by opioid toxicity

Yongxing Wang, 79, died from hypoxic brain injury caused by opioid toxicity from combined morphine and oxycodone. After a minor back injury on 21 August, he received a cortisone injection on 22 August with complications.…

general practiceradiologymedicationcommunicationmorphine
QLDhospital2017-10-23

Non Inquest Findings TO

73y · Male·Sepsis (gram-negative septic shock) secondary to complications of selective inte…

A 73-year-old man died from gram-negative septic shock following selective internal radiation therapy (SIRT) for metastatic gastric cancer. He had previously undergone a Whipple procedure in 2014, which creates a direct …

radiologyemergency medicinediagnosticmedication
QLDhospital2017-07-18

Stimpson, Reginald - Non-inquest findings

73y · Male·Acute intracranial haemorrhage, due to or as a consequence of coagulopathy, due …

Mr Stimpson, a 73-year-old man, died from massive intracerebral haemorrhage secondary to coagulopathy caused by inadvertent double administration of anticoagulants (Clexane and Xarelto). He developed bilateral pulmonary …

orthopaedic surgerygeneral medicinemedicationcommunicationenoxaparin
NSWhospital2016-10-26

Inquest into the death of Audrey MacGREGOR

88y · Female·combined effects of an overdose of hydromorphone and complications of pneumonia …

An 88-year-old woman with chronic lung disease, heart disease, and recent pneumonia following faecal transplant for clostridium difficile colitis was prescribed 0.5 mg hydromorphone subcutaneously for respiratory distres…

cardiologyrespiratory medicinemedicationcommunicationhydromorphone
QLDhospital2016-09-02

Calder, Michael James

33y · Male·Opiate toxicity

A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both slow-release (MS Co…

general medicineemergency medicinemedicationdiagnosticmorphine
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
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
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
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
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
VIChospital2015-07-29

Finding into death of Beatrix Dammers

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…

emergency medicineneurologydiagnosticmedicationenoxaparin
QLDhospital2015-07-27

KS - Non-inquest findings

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…

emergency medicinecardiologydiagnosticmedicationrivaroxaban
WAhospital2014-08-29

Inquest into the Death of Daniel LAHENGKING

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…

general practicepharmacydiagnosticmedicationmethotrexate
VIChospital2014-02-05

Finding into death of Margareta Snopek

67y · Female·Lithium toxicity with chest infection and bipolar disorder; Alzheimer's disease …

Mrs Snopek, aged 67 with bipolar disorder on long-term lithium, was prescribed coversyl (an ACE inhibitor) by Dr A. in January 2008 for hypertension. This combination is contraindicated as ACE inhibitors impair renal fun…

general practiceneurologymedicationdiagnosticlithium carbonate
VIChospital2014-01-21

Finding into death of Eddie Teck Chuan Lee

66y · Male·Intracerebral haemorrhage

A 66-year-old man with intracerebral haemorrhage and concurrent deep vein thrombosis died following an accidental tenfold heparin overdose. The patient received 20,000 units instead of 2,000 units due to a nurse misreadi…

neurosurgeryneurologymedicationsystemheparin
WAprison- 20 March 2014

Inquest into the Death of Anthony Nigel AXTELL

38y · Male·Heart failure in a man with dilated cardiomyopathy and focal severe coronary art…

Anthony Axtell, a 38-year-old man with severe dilated cardiomyopathy from amphetamine use, died of heart failure while in prison custody. Initially treated successfully in 2002 with recovery to normal cardiac function by…

cardiologycardiothoracic surgerymedicationsystemamphetamine

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