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QLDhospital2014-03-31

Platt, Christopher Robert Edmund - Non-inquest findings

69y · Male·Perforated bowel/septicaemia as a result of diverticulitis

A 69-year-old man presented to the ED with abdominal distension, incontinence and dehydration but was discharged with a diagnosis of depression and constipation. He returned 2 days later critically unwell and died of per…

emergency medicinegeneral surgerydiagnosticcommunicationsodium citrate enema
SAaged care2014-03-21

Coroner's Finding: MORGAN Beryl Jean

73y · Female·pneumonia and renal failure with hyperthermia

Beryl Jean Morgan, 73-year-old aged care resident, died from pneumonia and renal failure with hyperthermia after a brief hospital admission. She had been prescribed haloperidol for behavioural problems; while neuroleptic…

general practicegeriatric medicinediagnosticcommunicationhaloperidol
SAhospital2014-02-14

Coroner's Finding: RYAN John William and WALTON Patricia Dawn

Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…

Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…

anaesthesiaorthopaedic surgerydiagnosticcommunicationmorphine
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
QLDhospital2014-01-31

George, Lynda Margaret - Non-inquest findings

60y · Female·Peritonitis due to anastomotic leak following subtotal colectomy for treatment o…

60-year-old woman died from septic shock due to anastomotic leak following subtotal colectomy for synchronous bowel cancers. Early postoperative bronchospasm complicated clinical assessment, leading focus on respiratory …

general surgerycolorectal surgerydiagnosticcommunication
WAhospital- 8 July 2014

Inquest into the Death of Delray BEASLEY

56y · Male·unascertainable; complications of liver cirrhosis and/or exposure most likely

Delray Beasley, a 56-year-old Aboriginal man with chronic liver cirrhosis from longstanding alcohol abuse, was admitted to Kalgoorlie Hospital in May 2010 following an alleged assault. He was initially evaluated for poss…

emergency medicineneurosurgerysystemdiazepam
WAhospital- 27 May 2014

Inquest into the Death of Brian John DAVIES

57y · Male·Multiple Organ Failure and Intra-Abdominal Haemorrhage following Cholecystectomy

A 57-year-old man with multiple comorbidities (obesity, diabetes, hypertension, COAD, sleep apnoea) underwent elective laparoscopic cholecystectomy at a regional hospital. The procedure was converted to open due to dense…

surgeryanaesthesiasystemdelaymorphine
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
WAhospital2013-11-29

Inquest into the Death of Jones, Wilma Ray

75y · Female·Abdominal infection following surgery (repair of recurrent umbilical hernia) - s…

Wilma Ray Jones, 75, died of abdominal infection and sepsis following uncomplicated umbilical hernia repair. Post-mortem revealed ischaemic bowel with infarction, likely caused by superior mesenteric artery occlusion tri…

general surgeryanaesthesiadelaysystemephedrine
WAhospital2013-11-12

Inquest into the Death of Ford, Valma May Ruth

77y · Female·Complications following a recent fracture and surgical repair of the right hip i…

A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Ke…

orthopaedic surgeryemergency medicinediagnosticsystemwarfarin
SAhospital2013-08-19

Coroner's Finding: HUNT William Edward

62y · Male·chronic congestive cardiac failure due to severe aortic valve stenosis and incom…

William Edward Hunt, aged 62, a life-sentenced prisoner, died from chronic congestive cardiac failure due to severe aortic valve stenosis and cardiomyopathy. His severe aortic stenosis was identified in 2003, but surgica…

cardiologycardiothoracic surgerydelaycommunicationfurosemide
VICaged care2013-06-05

Finding into death of Stephen William Summers

55y · Male·Staphylococcal sepsis, complications of pressure sores and hypostatic pneumonia,…

Stephen Summers, a 55-year-old man with cerebral palsy and profound disability, died from Staphylococcal sepsis after rapid deterioration following deinstitutionalisation from Kew Cottages to community residential accomm…

general practiceemergency medicinediagnosticcommunication
QLD2013-05-27

Hussain, Meqdad

19y · Male·Hanging

Meqdad Hussain, a 19-year-old Afghan asylum seeker, died by hanging in an immigration detention centre (Scherger IDC, Queensland) on 17 March 2011. He had a history of self-harm evident from scars on his forearms, noted …

psychiatrygeneral medicinesystemcommunicationmirtazapine
QLDhospital2013-05-22

Thoresen, Cynthia

88y · Female·pulmonary thromboembolism due to fractured right femur due to a fall

Cynthia Thoresen, 88-year-old woman with dementia and osteoporosis, fell at home and sustained a fractured femur approximately three weeks before admission. Her daughter, the registered carer, failed to seek medical atte…

orthopaedic surgeryemergency medicinedelaysystemmorphine
VICmental health2013-05-10

Finding into death of Michael Desmond McWhirter

79y · Male·Acute Myocardial Infarction; Underlying multiple pathologies including vascular …

79-year-old man with complex medical history (ischaemic heart disease, pulmonary fibrosis, pacemaker, renal impairment, vascular dementia) died from acute myocardial infarction while in acute psychiatric care. He was tra…

psychiatrygeriatric medicinecommunicationsystemolanzapine
WAhospital2013-05-01

Inquest into the Death of Squires, John Gregory

47y · Male·Pulmonary thromboembolism in association with deep vein thrombosis

A 47-year-old man from Carnarvon underwent elective laparoscopic cholecystectomy at Geraldton Regional Hospital on 31 August 2009 after a 5-hour coach journey that morning. The VTE Risk Assessment Form correctly classifi…

surgeryanaesthesiadiagnosticdelayheparin
WAhospital2013-02-11

Inquest into the Death of Carroll

21y · Male·Acute hypoxic ischaemic encephalopathy and pneumonia in a man with recent trauma…

Peter Martin Carroll, age 21, died on 8 June 2007 in the ICU at Royal Perth Hospital from acute hypoxic ischaemic encephalopathy and pneumonia following oxycodone overdose. He had been discharged that day (5 June) after …

emergency medicineorthopaedic surgerycommunicationsystemoxycodone
WAhospital2013

Inquest into the Death of Mackenzie, Alexander Ronald

60y · Male·Pneumonia in a man with advanced metastatic angiosarcoma

A 60-year-old prisoner serving a life sentence died of pneumonia complicated by advanced metastatic angiosarcoma. He had two rare medical conditions: epithelioid angiosarcoma (diagnosed 2007) and aortitis. A significant …

haematologyallergy and immunologydiagnosticsystem
WA2013

Inquest into the Death of Lewis, Leslie Graham

57y · Male·Unable to be determined; circumstances suggest drowning in Mekong River or relat…

Leslie Graham Lewis, a 57-year-old Australian registered nurse, died in Thailand on 24 February 2011 in circumstances that remain unclear. He had been admitted to hospital in Nong Khai with severe alcohol intoxication an…

emergency medicinegeneral medicinedischargesystemalcohol
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
1891013

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