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QLDhospital2018-09-21

Baby M

0y · Female·Intracranial and intrapulmonary haemorrhage due to traumatic head injury from fa…

Baby M died shortly after birth on 11 February 2016 at Gladstone Base Hospital from intracranial and intrapulmonary haemorrhage due to traumatic head injury from a fall, complicated by Group B Streptococcal sepsis. A nur…

obstetricsmidwiferydiagnosticmedicationantibiotics
NSW2018-09-12

Inquest into the death of W

38y · Male·Multidrug toxicity

A 38-year-old man with multiple drug dependencies (alcohol, opioids, benzodiazepines) was admitted to a drug withdrawal facility for assisted detoxification. He received buprenorphine for opioid withdrawal management alo…

addiction medicineemergency medicinemedicationcommunicationbuprenorphine
VIChospital2018-08-21

Finding into death of Shane Kyle Tatti

27y · Male·Complications of snake bite

Shane Kyle Tatti, a 27-year-old gardener, died from complications of tiger snake envenomation. After a vigorous bite on 6 November 2014, he received one vial of tiger snake antivenom at Orbost Hospital 62 minutes post-bi…

emergency medicinetoxicologydiagnosticmedicationtiger snake antivenom
QLDhospital2018-08-20

RD - Non-inquest findings

64y · Male·Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia…

RD, a 64-year-old man with diabetes, amputation, and COPD, presented to a private hospital emergency department with suspected sepsis (vomiting, diarrhoea, hypotension, acute kidney injury, elevated troponin, hyperkalaem…

emergency medicineintensive carediagnosticmedicationintravenous normal saline
NSWhome2018-07-27

Inquest into the death of Alissa Campbell

26y · Female·Multiple drug toxicity

Alissa Campbell, aged 26, died from accidental drug overdose caused by multiple prescription medications—predominantly codeine and doxepin in combination with benzodiazepines. She had accessed prescription drugs from at …

general practiceaddiction medicinediagnosticmedicationcodeine
WAmental health2018-07-16

Inquest into the Death of Stanley KING

45y · Male·Cardiorespiratory arrest due to coronary artery disease, severe psychosis requir…

Stanley King, a 45-year-old man with severe psychosis, coronary artery disease, and obesity, died from cardiorespiratory arrest triggered by antipsychotic-induced laryngeal dystonia. Admitted involuntarily for acute psyc…

psychiatryemergency medicinediagnosticmedicationzuclopenthixol
NSWhospital2018-06-22

Inquest into the death of Manusiu Amone

0y · Female·ischaemic hypoxic encephalopathy secondary to factors associated with the sudden…

Manusiu Amone died from ischaemic hypoxic encephalopathy secondary to persistent pulmonary hypertension of the newborn (PPHN), not from pethidine toxicity as initially suspected. At 145 minutes of life, she developed gas…

obstetricsneonatologymedicationcommunicationpethidine
TAScommunity2018-06-20

Coroner's Finding: MB

23y · Male·mixed prescription drug toxicity (tramadol and alprazolam)

A 23-year-old male died from mixed prescription drug toxicity (tramadol and alprazolam) at a camping site. He had a history of depression, anxiety, self-harm, and previous overdose attempts. His mother provided unprescri…

general practicepsychiatrymedicationcommunicationtramadol
VIChospital2018-06-14

Finding into death of Ian John Gilbert

77y · Male·Complications of methotrexate toxicity in a man with chronic renal impairment, c…

A 77-year-old man with chronic kidney disease, COPD, and mild cardiac failure died from methotrexate toxicity after a GP prescribed it at an inappropriate daily dose (5mg daily) for psoriasis without baseline blood tests…

general practicepharmacydiagnosticmedicationmethotrexate
SAhospital2018-06-01

Coroner's Finding: MCRAE Christopher, PINXTEREN Johanna, HIGHAM Bronte, BAIRNSFATHER Carol - Ruling

Unknown·Acute myeloid leukaemia (AML)

Four patients with acute myeloid leukaemia (AML) died following administration of chemotherapy consolidation therapy that was delivered according to a protocol containing a critical error—specifying once-daily instead of…

haematologypharmacologymedicationsystemcytarabine
SAhospital2018-06-01

Coroner's Finding: MCRAE Christopher, PINXTEREN Johanna, HIGHAM Bronte, BAIRNSFATHER Carol

acute myeloid leukaemia

Four patients with acute myeloid leukaemia died after receiving chemotherapy consolidation therapy that was administered once daily instead of the intended twice daily schedule due to a protocol error. The error originat…

haematologyoncologymedicationsystemcytarabine
QLDhome2018-05-21

House, William John; White, Vanessa Joan; Smith, Jodie Anne and Milne, Daniel Keith

Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…

Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…

general practicepain medicinediagnosticmedicationfentanyl
TAShome2018-05-07

Coroner's Finding: Daniels, Scott Allen

44y · Male·Positional asphyxia

Scott Allen Daniels, a 44-year-old with chronic schizophrenia/schizoaffective disorder and substance abuse history, died from positional asphyxia on 17-19 March 2016. He consumed significant alcohol (BAC 0.220), cannabis…

psychiatryforensic medicinemedicationsystemalcohol
NSWhospital2018-03-29

Inquest into the death of Paul Lau

54y · Male·aspiration pneumonia caused by multiple drug toxicity

Paul Lau, aged 54, died from aspiration pneumonia caused by opioid toxicity following ACL reconstruction surgery. The death resulted from a prescribing error where anaesthetist Dr K. inadvertently prescribed a 100mcg/hou…

anaesthesiaorthopaedic surgerydiagnosticmedicationfentanyl
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
VIChospital2018-02-19

Finding into death of Margaret Ann Yeomans

79y · Female·Rhabdomyolysis in a woman with multiple myeloma and renal impairment

Margaret Ann Yeomans, aged 79, died from rhabdomyolysis in the context of multiple myeloma and chronic renal impairment. A critical medication error occurred when rosuvastatin 40mg was dispensed instead of her prescribed…

haematologynephrologymedicationcommunicationrosuvastatin
VIChospital2017-12-11

Finding into death of Karen Ann Moore

49y · Female·Bronchopneumonia, hypoxic brain injury, and combined drug toxicity (oxycodone an…

Karen Moore, aged 49, died from bronchopneumonia following hypoxic brain injury caused by combined drug toxicity (oxycodone and diazepam). She was found unconscious at home after an overdose and did not regain consciousn…

general practiceemergency medicinemedicationcommunicationoxycodone
VIChome2017-12-04

Finding into death of Leigh Thomas Aiple

31y · Male·Pulmonary thromboembolism

A 31-year-old man with obesity (BMI 40.2) and sleep apnoea underwent extensive cosmetic surgery in Malaysia (liposuction, abdominoplasty, chest lipectomy, and subsequent facial procedures) across two operations within fi…

plastic and reconstructive surgerygeneral surgerydiagnosticmedicationenoxaparin
NSW2017-11-06

Inquest into the death of Edward Haenga

37y · Male·cardiac arrhythmia

A 37-year-old man died in custody from cardiac arrhythmia, with morbid obesity and concurrent psychotropic medications carrying QT-prolongation risk identified as contributing factors. Key clinical lessons include: (1) p…

psychiatrygeneral practicemedicationproceduralescitalopram
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
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