Coronial
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TAShospital2024-10-18

Coroner's Finding: Long, Leonard

73y · Male·subdural haematoma from fall

Leonard Athol Long, a 73-year-old on warfarin for mechanical mitral valve replacement, fell twice during hospitalization for urinary tract infection. He was on SMZ-TMP antibiotics, which interact significantly with warfa…

general medicineemergency medicinediagnosticsystemwarfarin
TAShospital2024-10-11

Coroner's Finding: Vieth, Karl Heinz

92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…

A 92-year-old man with complex cardiac history was admitted to Royal Hobart Hospital with chest pain and atrial fibrillation. He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, …

general medicineemergency medicinesystemdelaymelatonin
TAShospital2024-09-30

Coroner's Finding: Newell, Warren James

71y · Male·raised intracranial pressure caused by left frontal-temporal-parietal subdural h…

Warren James Newell, a 71-year-old man with oesophageal cancer, presented with acute coronary syndrome on 29 September 2022 and was appropriately diagnosed and treated with anticoagulation and dual antiplatelet therapy. …

cardiologyemergency medicinemedicationsystemenoxaparin
WAhospital2024-09-24

Inquest into the death of Raymond Sydney CHEEK

89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…

Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarin…

emergency medicineendocrinologymedicationsystemryzodeg insulin
SA2024-09-13

Coroner's Finding: Mortess, Noel Allen

75y · Male·End stage myelodysplastic syndrome and end stage renal failure on a background o…

A 75-year-old man died in prison custody from end-stage myelodysplastic syndrome and renal failure on a background of ischaemic heart disease, hypertension, valvular disease, and metastatic prostate cancer. He was admitt…

general medicinehaematologydelaysystemcefuroxime
QLDaged care2024-08-22

Non-inquest findings into the death of Malcolm Daniel Moriarty

87y · Male·Combined effects of sotalol toxicity on a background of severe valvular and athe…

An 87-year-old man with Alzheimer's disease died in a residential aged care facility after ingesting Sotalol, a cardiac medication not prescribed to him. The medication trolley was left unlocked and accessible despite fa…

geriatric medicinegeneral practicemedicationproceduralsotalol
QLDhospital2024-08-13

Non-inquest findings into the death of RJH

70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide card…

A 70-year-old woman with complex cardiac history including heart failure, paroxysmal atrial fibrillation, and coronary atherosclerosis presented with urinary tract infection and atrial fibrillation on Christmas Day 2021.…

cardiologyemergency medicinediagnosticmedicationflecainide
QLDhospital2024-07-30

PATELESIO, Etevise

29y · Female·Hypoxic-ischaemic encephalopathy due to cardiac arrest of undetermined cause

A 29-year-old woman with multiple comorbidities (Turner syndrome, type 1 diabetes, end-stage renal disease) presented to the ED in acute behavioural disturbance, requiring physical and chemical restraint. She received 5m…

emergency medicineintensive caremonitoringsystemdroperidol
VIChospital2024-07-29

Finding into death of Shane Anthony Pappas

54y · Male·quetiapine toxicity in a man with ischaemic heart disease

Shane Pappas, a 54-year-old man with ischaemic heart disease, died from quetiapine toxicity after deliberately overdosing on multiple medications on 29 June 2021. He had experienced a recent relationship breakdown and pr…

psychiatryemergency medicinediagnosticcommunicationquetiapine
WAmental health2024-07-19

Inquest into the Death of Phillip Benjamin VELTMAN

49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…

Phillip Veltman, 49, died of unascertained cause (likely cardiac arrhythmia with terminal aspiration) while an involuntary psychiatric patient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on…

psychiatryemergency medicinecommunicationsystemketamine
NSW2024-06-20

Inquest into the death of Michael Baker

44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…

Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…

general practicepsychiatrydiagnosticcommunicationmethadone
SAaged care2024-06-19

Coroner's Finding: Whelan, Brian John

84y · Male·head and pelvic injuries with contributing ischaemic and valvular heart disease …

An 84-year-old man under guardianship with dementia, cardiac disease, and on anticoagulation suffered an unwitnessed fall at an aged care facility and sustained head and pelvic injuries. Following the fall, a registered …

geriatric medicineemergency medicinesystemcommunicationanticoagulation medication
QLD2024-06-18

Inquest into the deaths of Shiralee Deanne Tilberoo and Vlasta Wylucki

Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…

Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…

cardiologyaddiction medicineproceduralcommunicationdiazepam
VIChospital2024-06-14

Finding into death of Joshua Paul Coates

49y · Male·Acute myocardial infarction complicating prosthetic valve thrombosis in a man wi…

Joshua Paul Coates, aged 49, died from acute myocardial infarction complicating prosthetic valve thrombosis following mechanical aortic valve replacement. Post-mortem examination revealed a large blood clot obstructing h…

cardiothoracic surgerycardiologycommunicationsystemwarfarin
NT2024-06-12

Inquest into the death of Mr Dooley

37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia

Glen Dooley, a 37-year-old Aboriginal man, died of atherosclerotic heart disease and dyslipidaemia while in custody at Darwin Correctional Centre. His death was avoidable. He had abnormal ECGs in 2019 and 2022 that were …

cardiologygeneral practicediagnosticcommunicationatorvastatin
VIChospital2024-05-24

Finding into death of Jacob William Kennedy

36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…

Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He was administered multiple s…

psychiatryaddiction medicinemedicationproceduralmethadone
NSW2024-05-21

Inquest into the death of Mohamed Warwar

35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…

35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues an…

psychiatrycardiologycommunicationdiagnosticamisulpride
VIChospital2024-05-06

Finding into death of Errol Leslie Solly

67y · Male·Ischaemic heart disease; coronary artery atherosclerosis (stented)

A 67-year-old man with extensive cardiac history presented to the ED with recurrent ischaemic-sounding chest pain. Despite multiple episodes of chest pain during admission, initial ECGs and troponins were normal. Followi…

emergency medicinecardiologydiagnosticcommunicationmorphine
NSWcommunity2024-05-03

Inquest into the death of Keith Titmuss

20y · Male·exertional heat stroke

A 20-year-old professional rugby league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest aerobic fitness of hi…

sports medicineemergency medicinesystemdelaymidazolam
VIChome2024-04-23

Finding into death of Robert Norman Spencer

59y · Male·ischaemic heart disease in the setting of chronic ethanol use

Robert Spencer, 59, called 000 at 4:27 am reporting weakness and inability to mobilise following a fall. He was triaged as Code 3 (non-urgent) and underwent secondary triage call-back attempts without success. An ambulan…

emergency medicineparamedicinesystemdelay
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