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VIChospital2018-01-18

Finding into death of Kathryn Maree Jelbart

59y · Female·Multiorgan failure and polymicrobial sepsis secondary to severe bone marrow fail…

A 59-year-old woman with renal transplant died from multiorgan failure and sepsis secondary to severe bone marrow failure caused by azathioprine toxicity. She had an undiagnosed genetic polymorphism (TPMT *3A/*3A homozyg…

nephrologytransplant medicinediagnosticsystemazathioprine
VIChospital2017-12-21

Finding into death of Sally Elizabeth Hopwood

57y · Female·Haemothorax following acute thoracic aortic dissection in a woman with congenita…

Sally Hopwood, 57, with Turner syndrome, coarctation of the aorta, and bicuspid aortic valve, presented to ED on 23 March 2012 with severe acute back and chest pain (8/10). A chest X-ray revealed widened mediastinum. She…

cardiologyemergency medicinediagnosticcommunicationglyceryl trinitrate
TASmental health2017-11-17

Coroner's Finding: Smith, Molly Jessie

75y · Female·pyelonephritis and pneumonia

Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …

psychiatrygeneral practicediagnosticdelaycefalexin
QLD2017-08-04

Mrs H - Non-inquest findings

76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed

A 76-year-old woman with chronic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital fo…

general medicinegastroenterologydiagnosticcommunicationibuprofen
QLDhospital2017-06-22

Mead, Gwendoline

73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…

73-year-old woman died 12 days after elective colorectal surgery for synchronous caecal and rectal tumours. Post-operatively, she developed persistent low urine output and intermittent hypotension managed with repeated f…

colorectal surgerygeneral surgerydiagnosticdelay5-fluorouracil
WAhospital2017-05-03

Inquest into the Death of Edith Catherine BEE

80y · Female·Gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm …

An 80-year-old woman with multiple comorbidities (COPD, renal impairment, cardiac disease) underwent complex endoluminal repair of a thoracoabdominal aortic aneurysm at a private hospital. The procedure required use of C…

vascular surgerygeneral surgeryproceduralsystem
QLDhome2017-02-07

ES, a 87 year old lady

87y · Female·Multiple opioid drug toxicity (morphine and fentanyl) in combination with conges…

An 87-year-old woman with multiple comorbidities (ischaemic heart disease, emphysema, chronic kidney disease) was discharged home for palliative care after a hospital admission. Her family administered excessive doses of…

general practicepalliative caremedicationcommunicationmorphine
QLDhospital2016-07-08

Talbot, James Patrick

87y · Male·Strangulated small bowel due to adhesions from previous abdominal surgery

An 87-year-old man with diabetes, hypertension and dementia was admitted with presumed UTI and dehydration. Within 24 hours, nursing staff observed a distended abdomen and bile-stained vomiting—clinical signs of bowel ob…

general medicinenephrologydiagnosticcommunicationondansetron
WAhospital2016-05-18

Inquest into the Death of Janice May SAULYS

69y · Female·multi-organ failure due to sepsis of unknown origin

A 69-year-old woman with diabetes, cardiac disease, and vulnerable kidneys died from multi-organ failure due to sepsis of unknown origin. She presented to a rural hospital on 28 June 2012 with vomiting, dehydration, and …

emergency medicinegeneral practicesystemdelay
NT2015-08-14

Inquest into the death of Virginia Brown

46y · Female·Cardiac arrest of unknown origin

Virginia Brown, a 46-year-old Aboriginal woman, died of cardiac arrest of unknown origin on 31 October 2014 while detained under a Mandatory Residential Treatment (MRT) order at CAAAPU (Central Australian Aboriginal Alco…

emergency medicineaddiction medicinediagnosticcommunicationsodium_valproate
NSWhospital2014-11-19

Inquests into the death of Luke WOOD

35y · Male·intraperitoneal haemorrhage from an anastomotic leak from a transplanted renal a…

Luke Wood, a 35-year-old kidney transplant recipient, died 11 days post-transplant from intraperitoneal haemorrhage due to anastomotic leak from the transplanted renal artery. While post-operative inpatient care and init…

transplant medicinenephrologycommunicationsystemlymphocyte immune globulin, anti-thymocyte globulin
VIChospital2014-09-12

Finding into death of Nola Margaret Moxon

77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression

77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission, no medical review occurred over the weekend prior to …

psychiatrygeriatric medicinecommunicationsystemvenlafaxine
VIChospital2014-07-14

Finding into death of Mary Una Barnett

71y · Female·Diffuse Lymphoid Malignancy

Mary Una Barnett, a 71-year-old woman in custody at Dame Phyllis Frost Centre, died from diffuse lymphoid malignancy (high-grade lymphoma) discovered shortly before her death. She had extensive comorbidities including ch…

cardiologynephrologysystemdelay
ACThospital2014-03-03

Findings Into The Death Of Sukanya Thurairajah

56y · Female·hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and f…

Sukanya Thurairajah, 55-year-old with multiple comorbidities including obesity, diabetes, coronary disease, and metastatic breast cancer, underwent haemodialysis at Canberra Hospital on 29 July 2011. She had an adverse r…

anaesthesiaintensive careproceduralcommunicationhydrocortisone
WAmental health- 11 April 2014

Inquest into the Death of Amanda Alison GILBERT

47y · Female·bronchopneumonia in context of ischaemic heart disease, chronic renal failure, a…

Amanda Gilbert, aged 47, died from bronchopneumonia with background ischaemic heart disease, chronic renal failure, and hypoxic brain injury from a 1985 hanging attempt. She had been an involuntary patient at Graylands H…

psychiatrygeneral medicinesystemdelaylithium
VIChospital2013-05-07

Finding into death of Gurpal Sandhu

64y · Female·Lymphocytic choriomeningitis virus (LCMV)-like arenavirus infection, post liver …

A 64-year-old woman died on 3 January 2007 from a lymphocytic choriomeningitis virus (LCMV)-like arenavirus acquired through cadaveric liver transplantation. The donor had recently returned from Serbia with unexplained w…

transplant medicinehepatologycommunicationsystem
VIChospital2013-05-07

Finding into death of Carmelina Rachela Sirianni

63y · Female·Lymphocytic choriomeningitis virus (LCMV)-like virus infection; post failed rena…

A 63-year-old woman received a renal transplant from a cadaveric donor who had died of cerebral hemorrhage. She developed delayed graft function and deteriorated post-operatively, ultimately dying from a novel lymphocyti…

nephrologytransplant medicinecommunicationsystem
VIChospital2013-05-07

Finding into death of Karen Elizabeth Wilkinson

44y · Female·Lymphocytic choriomeningitis virus (LCMV)-like virus infection following failed …

A 44-year-old woman died on 1 January 2007, six days after receiving a cadaveric renal transplant. She was one of three organ recipients from the same donor who died within six days of each other from a novel lymphocytic…

transplant medicinenephrologycommunicationsystem
WA2013

Inquest into the Death of Bropho, Robert Charles

81y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis

Robert Charles Bropho, an 81-year-old Aboriginal man imprisoned since 2008 with severe medical comorbidities including insulin-dependent diabetes, hypertension, chronic renal failure, and severe ischaemic heart disease, …

cardiologygeneral medicinecommunicationsysteminsulin
QLDhospital2012-12-07

Cooper, Gerry Maxwell

57y · Male·Hepatic encephalopathy, end stage liver failure, alcoholic cirrhosis, end stage …

Gerry Maxwell Cooper, a 57-year-old Aboriginal man imprisoned for 23 years, died in PAH Secure Unit from natural causes: hepatic encephalopathy, end-stage liver failure, alcoholic cirrhosis, and end-stage renal failure. …

nephrologyhepatologysystemasasantin

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