158 results
1y · Female·Rapidly developing Streptococcus pneumoniae infection leading to invasive pneumo…
Arianna Maragol, a 16-month-old girl, died from rapidly developing Streptococcus pneumoniae infection leading to invasive pneumococcal disease while in childcare on 24 August 2018. Key clinical lessons emerged: (1) Pneum…
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 …
60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…
A 60-year-old man remanded in custody died from pulmonary tuberculosis complicated by severe COPD. Key clinical issues included: delayed diagnosis (TB not suspected at intake despite respiratory symptoms), patient's refu…
43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…
Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …
55y · Female·acute necrotising bronchopneumonia
MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…
76y · Female·sepsis as a result of myocarditis and tricuspid valve endocarditis (infective en…
A 76-year-old woman with vascular dementia and emphysema was admitted with sepsis of unknown origin, treated with antibiotics, and discharged after 12 days with improving symptoms. She re-presented 14 days later with rec…
83y · Male·Sepsis due to staphylococcus aureus bacteraemia following infection of a left an…
An 83-year-old man with heart and kidney failure died from sepsis caused by MSSA bacteraemia following infection at a peripheral intravenous catheter (PIVC) insertion site. Ambulance paramedics inserted the PIVC 56 hours…
65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …
A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…
54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …
Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarce…
26y · Male·Multi-organ failure due to pneumococcal septic shock
A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…
3y · Female·Streptococcus pyogenes septicaemia
A three-year-old girl with Down syndrome died from Group A Streptococcus septicaemia after a 10-day illness. She presented four times to hospital (ED and rapid review clinic) over three days with fever, rash, and diarrho…
74y · Male·Congestive heart failure on a background of recent influenza A infection, end st…
Frederick William Boyle, aged 74, died of congestive heart failure in the setting of influenza A infection, end-stage dementia, and Parkinson's disease while in Port Phillip Prison. He had been transferred from St Vincen…
24y · Female·Pulmonary and miliary tuberculosis
Manpreet Kaur, a 24-year-old Indian national on a student visa, died of pulmonary and miliary tuberculosis on 20 June 2024 at Melbourne Airport. She had been symptomatic for months, presenting to a GP on 19 May 2024 with…
46y · Female·Hepatic encephalopathy due to decompensated Child-Pugh C cirrhosis and meningiti…
This combined coronial finding examines three deaths at the Centre for National Resilience (CNR), a COVID-19 quarantine facility in Howard Springs. Ms Dick died from rapidly progressive melioidosis. David Hardy died from…
45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia
A 45-year-old Aboriginal man with poorly managed diabetes and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs i…
78y · Female·Complications of prolonged immobility and malnutrition in a woman with retroperi…
A 78-year-old woman with schizophrenia, depression, and undiagnosed retroperitoneal lymphoma died from septic shock complicating severe pressure ulcers, malnutrition, and dehydration. She had been immobile on a couch for…
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection
A two-year-old girl died from complications of severe iron-deficiency anaemia and COVID-19 infection. She had significant feeding difficulties, took almost exclusively milk and yoghurt, and was profoundly anaemic with po…
3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…
Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…
74y · Male·Sepsis secondary to fistulating Crohn's disease and post-surgery complications f…
Christopher Essery, a 74-year-old man with complex fistulating Crohn's disease, died from sepsis following surgery on 24 January 2019. He was transferred to Princess Alexandra Hospital (PAH) on 31 August 2018 for special…
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