Coronial
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VIC2024-08-12

Finding into death of Danielle Cadan

51y · Female·Methemoglobinemia in the context of lignocaine use

Danielle Cadan, 51, died from methemoglobinemia following a tooth extraction under lignocaine anaesthetic at a regional health service. The lignocaine was administered in normal therapeutic dose but triggered this rare l…

dentistryanaesthesiacommunicationsystemlidocaine
TAShospital2023-11-17

Coroner's Finding: Williams, Stewart

54y · Male·Hypoxic/ischaemic brain damage caused by blood loss and airway obstruction due t…

A 54-year-old male was assaulted in a nightclub with a single punch causing orbital and facial fractures and posterior epistaxis. He presented to the Royal Hobart Hospital ED with active bleeding. Critical deficits in hi…

emergency medicineoral and maxillofacial surgerydiagnosticcommunication
NSWhospital2023-10-31

Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…

Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…

intensive careanaesthesiadiagnosticproceduralrocuronium
VIC2023-07-19

Finding into death of Angela Cuthbert

59y · Female·complications of abscesses following dental extraction, in a woman with cerebral…

Angela Cuthbert, a 59-year-old woman with severe cerebral palsy and dysphagia, died from complications of abscesses following extraction of all 14 teeth under general anaesthetic. Surgery occurred 20 June 2022; she devel…

oral and maxillofacial surgerydentistrycommunicationsystem
TAShome2023-05-04

Coroner's Finding: Chuah Soo Lan

65y · Female·undetermined; possibly ischaemic heart disease or squamous cell carcinoma of ton…

A 65-year-old Malaysian woman with advanced squamous cell carcinoma of the tongue refused medical treatment due to visa concerns and preference for alternative therapy. She deteriorated over months with worsening oral sy…

oncologydentistrydelaysystem
WA2022-09-15

Inquest into the Death of Leslie SHORTTE

71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)

Leslie Shortte, a 71-year-old life prisoner, died from metastatic squamous cell carcinoma with complications. Critical failures in his prison medical care included: failure to complete annual health assessments after 201…

oncologypalliative carediagnosticcommunicationlidocaine
WAhospital2022-08-02

Inquest into the Death of Henry ALLEN

60y · Male·sepsis and aspiration pneumonia in a man with oral squamous cell carcinoma and m…

Henry Allen, a 60-year-old man with oral squamous cell carcinoma, lung cancer, and multiple comorbidities died from sepsis and aspiration pneumonia while in prison custody at Fiona Stanley Hospital. He received appropria…

oncologypalliative caresystemdelayoxycodone
QLDhospital2022-07-08

R - Non-inquest findings

<1y · 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
WAhospital2021-09-29

Inquest into the Death of Robert Charles CRAIG

73y · Male·Disseminated malignancy (advanced lung carcinoma and mouth carcinoma) in a man w…

Robert Craig, aged 73, died from disseminated malignancy (advanced lung and mouth carcinoma) while in prison custody. He received suboptimal cancer treatment at Fiona Stanley Hospital due to communication failures betwee…

oncologyradiation oncologydiagnosticcommunicationcetuximab
VIC2020-12-09

Finding into death of Alma Lynette Honeychurch

76y · Female·Ludwig's angina

A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognis…

emergency medicinedentistrydiagnosticcommunicationantibiotics
NSWhospital2020-02-28

Inquest into the death of Peter ROBIN

56y · Male·Pulmonary embolism with deep vein thrombosis an antecedent cause; coronary arter…

Peter Robin, a 56-year-old man with a medical history of hypercholesterolaemia, hypertension, obesity, and depression, underwent elective dental surgery on 28 October 2015 to remove four wisdom teeth and resect a cyst. H…

oral and maxillofacial surgeryanaesthesiacommunicationsystemoxycodone
VIC2020-01-15

Finding into death of Travis Lee Fernandez

35y · Male·Hanging

Travis Lee Fernandez, aged 35, died by hanging in custody at Dhurringile Prison in November 2014. He had sustained bilateral mandibular fractures in January 2014 treated with open reduction and internal fixation (ORIF). …

oral and maxillofacial surgeryemergency medicinecommunicationsystemmethadone
VIChospital2018-11-26

Finding into death of Sarah Hammoud

22y · Female·septic shock complicating osteomyelitis secondary to cellulitis in a woman with …

Sarah Hammoud, aged 22 with cerebral palsy and intellectual disability, died from septic shock complicating osteomyelitis secondary to cellulitis. She resided in a supported residential service and had recurrent elbow in…

general practiceorthopaedic surgerycommunicationsystemantibiotics
VIChome2018-06-28

Finding into death of Raymond John Cox

84y · Male·Gunshot wound to the head

Raymond John Cox, an 84-year-old man with Alzheimer's disease, depression, and cognitive decline, died from a self-inflicted gunshot wound to the head. His wife had approached police in 2013 seeking assistance to remove …

general practicegeriatric medicinecommunicationsystemcitalopram
NSWhospital2011-08-12

Godden,george 2011 08 31 14 50 44 877

Unknown·Lignocaine toxicity following dental surgery with atherosclerotic and valvular h…

George Godden died at Prince of Wales Hospital on 22 February 2007 from lignocaine toxicity following dental surgery. His post-extraction gingival bleeding was treated with gauze soaked in co-phenylcaine spray, a medicat…

dentistrygeneral medicinemedicationprocedurallidocaine
SAhospital2006-11-13

Coroner's Finding: SALMON Daniel Brindley

27y · Male·Airway obstruction due to sublingual and submandibular cellulitis (Ludwig's angi…

A 27-year-old man died from airway obstruction due to Ludwig's angina (bilateral sublingual and submandibular cellulitis) following a tooth extraction. Critical failures included: delayed treatment with inadequate timely…

emergency medicinedentistrycommunicationdiagnosticparacetamol/codeine
QLDhospital2005-08-24

Sabadina, Kathryn Marnie

28y · Female·Anaphylactic reaction to anaesthetic drug (suxamethonium), with underlying coron…

A 28-year-old woman died during routine dental extraction under general anaesthesia at a regional hospital. Despite competent initial airway management, she developed severe respiratory distress immediately after inducti…

anaesthesiadentistrydiagnosticproceduralpropofol
WAhospital2003-08

Inquest into the Death of Richard Christopher Jankowski

39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…

Richard Christopher Jankowski, a 39-year-old man, died from hypoxic brain injury due to respiratory obstruction following emergency surgery for a dental abscess with cellulitis. After initial treatment with antibiotics, …

anaesthesiageneral surgeryproceduralcommunicationpropofol

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