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SAhospital2026-04-23

Coroner's Finding: Wilson, Charles Thomas

85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …

An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …

cardiologygeriatric medicinemedicationcommunicationmetoprolol
SAhospital2026-03-30

Coroner's Finding: Chadha, Hemant and Battagodage, Sachintha Nandula

Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…

Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…

emergency medicinegeneral practicediagnosticcommunicationdiazepam
TAShome2026-02-17

Coroner's Finding: Gregory and Diane Burkhalter

73y · Male·Gregory Frank Burkhalter: carbon monoxide toxicity due to inhalation of carbon m…

Two elderly US-born residents died in a house fire caused by a 120-volt electric blanket operating on Australia's 230-volt grid, resulting in insulation failure and combustion. Mr Burkhalter (73) died from carbon monoxid…

emergency medicineanaesthesiasystem
SAhospital2025-11-05

Coroner's Finding: Jackson, Dennis Charles

67y · Male·Type 2 respiratory failure due to pneumonia

Dennis Jackson, a 67-year-old from Broken Hill, underwent left upper lobe lobectomy based on a falsely positive lung biopsy contaminated with squamous cell carcinoma tissue from another patient during processing at SA Pa…

cardiothoracic surgerypathologydiagnosticsystem
QLD2025-10-08

Inquest into the death of Peter Owen Pilkington

48y · Male·gunshot wound to chest

Peter Owen Pilkington, 48, died from a gunshot wound sustained during a police siege on 6 December 2021. After escalating behaviour at his NDIS support office in Stretton, Queensland, Peter produced what police believed …

emergency medicinetrauma surgerysystemmethamphetamine
VIChospital2025-04-03

Finding into death of Alan John Trevor Deem

67y · Male·Intracranial haemorrhage complicating coronary artery bypass graft surgery follo…

A 67-year-old man died from intracranial haemorrhage following coronary artery bypass graft surgery. He had suffered a right coronary artery dissection during percutaneous coronary intervention at Sunshine Hospital and w…

cardiologycardiothoracic surgerycommunicationsystemdual anti-platelet agents
VIChospital2024-09-26

Finding into death of FH C

11y · Male·Sepsis

An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…

emergency medicinepaediatricsdiagnosticcommunicationrisperidone
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
NSWhospital2024-01-29

Inquest into the death of Sean Montgomery

70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia

70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…

cardiothoracic surgerygeneral surgerydiagnosticcommunicationmorphine
VIChospital2023-07-17

Finding into death of Sasha

12y · Female·Hypoxic ischaemic encephalopathy complicating an aortic root abscess (operated) …

A 12-year-old Aboriginal girl with a bicuspid aortic valve and autism spectrum disorder presented with a week of fever and non-specific symptoms (cough, vomiting, abdominal pain, chest pain) to a rural hospital. Despite …

paediatricsinfectious diseasescommunicationsystem
VIChospital2023-06-23

Finding into death of Edis Vytas Brenner

78y · Male·Multiorgan failure consequent upon pulmonary lacerations and haemorrhage sustain…

A 78-year-old man died from multiorgan failure following complications during planned mitral and tricuspid valve surgery. During the initial surgery, a small superficial laceration to the right lower lobe lung occurred, …

cardiothoracic surgeryintensive caresystem
SAhospital2023-03-01

Coroner's Finding: Coats, Beverley Joy and West, Heather Maud and DSouza, Lorna Margaret

Female·haemopericardium due to aortic dissection (all three cases)

Three elderly women died from acute aortic dissection at Queen Elizabeth Hospital, South Australia. Beverley Coats (73) presented three times in July 2016 with back pain, nausea and vomiting; her known aortic dilatation …

emergency medicinecardiologydiagnosticcommunication
VICaged care2022-11-30

Finding into death of Ian Dunlop

74y · Male·Pericarditis post aortic valve surgery with large pericardial effusion leading t…

Ian Dunlop, a 74-year-old man, died from pericarditis with large pericardial effusion and tamponade four days after aortic valve replacement surgery. Post-operative imaging showed a small pericardial effusion, considered…

cardiothoracic surgerycardiologycommunicationsystemapixaban
VIChospital2022-10-18

Finding into death of Warren Douglas Frazer

45y · Male·Complications of VATS procedure for locally advanced right upper lobe lung adeno…

A 45-year-old man died from complications following VATS lobectomy for lung adenocarcinoma. During initial surgery, the tumour invaded the T6 vertebral body. The surgeon, faced with incomplete tumour resection or vertebr…

cardiothoracic surgeryneurosurgerydiagnosticdelay
WA2022-07-20

Inquest into the Death of Seth Gregory Victor YEEDA

19y · Male·Rheumatic heart disease (severe aortic valve regurgitation)

Seth Yeeda, 19-year-old Aboriginal male with rheumatic heart disease from childhood, died in custody from severe aortic valve regurgitation. He had required aortic valve replacement surgery since 2014. In December 2017, …

cardiologycardiothoracic surgerysystemcommunication
QLDhospital2022-07-08

R - Non-inquest findings

0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…

A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…

anaesthesiaintensive carediagnosticproceduralpropofol
VIChospital2022-03-15

Finding into death of Ann Leah Jones

87y · Female·Pulmonary artery rupture complicating pulmonary artery catheter insertion in a w…

Mrs Jones, an 87-year-old woman with severe ischaemic heart disease, died from pulmonary artery rupture during elective off-pump coronary artery bypass surgery. A Swan-Ganz pulmonary artery catheter (PAC) was inserted pr…

cardiothoracic surgeryanaesthesiaproceduralsystemfentanyl
NSWhospital2021-04-16

Inquest into the death of Kelvin MOULDS

61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a c…

Kelvin Moulds, a 61-year-old man, died of hypoxic encephalopathy following a cardiac arrest caused by self-removal of a central venous catheter (CVC) on day 14 post-bilateral lung transplant. The CVC was still in situ de…

cardiothoracic surgerytransplant medicinecommunicationsystemoxycodone
VIChospital2021-02-26

Finding into death of Ian Fraser

68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…

Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…

respiratory medicinecardiothoracic surgerymedicationsystemapixaban
VIChospital2020-11-25

Finding into death of Eoghan Jerome Arnold

42y · Male·Hypoxic ischaemic brain injury secondary to cardiac arrest caused by massive pul…

A 42-year-old man died from hypoxic ischaemic brain injury following cardiac arrest due to a massive pulmonary embolism. He sustained a tibial fracture in a motor vehicle accident and underwent external fixation. He deve…

orthopaedic surgeryanaesthesiasystemenoxaparin

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