157 results
38y · Male·mixed drug toxicity and arrhythmogenic right ventricular dysplasia
Shane Andrew Kromwyk, aged 38, died at home on 14 March 2009 while on home detention bail. Post-mortem examination revealed mixed drug toxicity (methadone, diazepam, alprazolam) combined with pre-existing arrhythmogenic …
68y · Male·Dilated cardiomyopathy with previous aortic valve replacement and aortic graft
A 68-year-old man with aortic valve replacement died from undiagnosed dilated cardiomyopathy, with retroperitoneal haemorrhage as a contributing factor. He developed a large perinephric haematoma (1900mL) secondary to ov…
30y · Male·asphyxia due to hanging (suicide)
30-year-old Adam Trent Ryan died by suicide via hanging in July 2009. Multiple systemic failures preceded his death. The Community Mental Health Service failed to communicate Mr Ryan's past suicide attempt to the hospita…
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…
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…
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…
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…
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…
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…
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'…
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…
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:…
63y · Male·cerebral infarction
John Arthur Burns, a 63-year-old man with frontotemporal dementia and motor neurone disease, died from cerebral infarction on 17 September 2006 while in Westminster Aged Care Facility after only 12 days of residence. Des…
28y · Female·bronchopneumonia complicating oxycodone toxicity
Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropri…
2y · Female·pneumonia in a toddler with enlarged tonsils and presence of codeine in blood
Elanur Koc, a 2-year-old with a history of recurrent throat infections and enlarged tonsils, died from pneumonia. Significant codeine was detected in her blood, urine, liver, and stomach contents, with codeine also prese…
37y · Male·Mixed drug toxicity (heroin, methadone and diazepam) in a man with coronary arte…
Michael Gledhill, 37, died from mixed drug toxicity involving heroin, methadone, and diazepam, complicated by pre-existing coronary artery disease. He was enrolled in a methadone maintenance program but continued illicit…
20y · Male·pulmonary oedema due to acute on chronic heart failure resulting from dothiepin …
A 20-year-old man died from pulmonary oedema due to acute-on-chronic heart failure resulting from dothiepin overdose. He had complex mental health and substance use issues dating back to age 16. He was prescribed dothiep…
81y · Male·bronchopneumonia
An 81-year-old man with dementia, congestive cardiac failure, chronic lung disease and hip fractures died of bronchopneumonia four days after discharge from palliative care to a nursing home. While an administrative erro…
29y · Female·Invasive aspergillosis
A 29-year-old registered nurse with systemic lupus erythematosus (SLE) died from invasive aspergillosis. Dr G. prescribed lamotrigine 100 mg daily (double the recommended initial dose of 50 mg) on first consultation with…
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…
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