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NThospital2008-09-04

Inquest into the death of Margaret Winter

64y · Female·acute subdural haemorrhage sustained after a fall on Ward 4A

Margaret Winter, 64, died from acute subdural haemorrhage following a fall on Ward 4A on 13 December 2006. She had been admitted with decompensated liver disease. Her falls risk was misclassified as low when it should ha…

general medicineneurologydiagnosticcommunication
WA2008-07-07

Inquest into the Death of Kirsty Anne Slater

24y · Female·Ligature compression injury to the neck (hanging)

Kirsty Anne Slater, a 24-year-old woman with extensive mental illness and substance abuse history, was found hanging from a tree in a park on 19 April 2006, nine days after absconding from Fremantle Hospital's Alma Stree…

psychiatryintensive carecommunicationsystemmorphine
QLDhospital2007-12-07

Burgen, Deborah Denise

49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…

Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with identical …

emergency medicinesurgerydiagnosticdelayparacetamol/codeine
QLD2007-11-28

Tanner, Marjorie Joyce

Female·Coronary atherosclerosis with ischaemic small bowel and Alzheimer's disease

Marjorie Joyce Tanner, an elderly woman with Alzheimer's disease, presented to Maryborough Hospital with a three-day history of abdominal pain, distension, and vomiting. Initially diagnosed with simple constipation and t…

general medicinesurgerydiagnosticsystemmetoclopramide
QLDhospital2007-11-23

Scholz, Karl David

31y · Male·Upper airway obstruction due to pharyngeal abscess caused by dental abscess, whi…

Karl Scholz, 31-year-old male, died from upper airway obstruction due to pharyngeal abscess originating from untreated dental infection. He presented with severe facial cellulitis and abscess following dental procedures …

intensive careanaesthesiadiagnosticcommunicationamoxicillin
QLDhospital2007-10-29

Cvitic, Nardia Annett

30y · Female·Multi-organ failure due to multiple transfusions required for post-operative ble…

Ms Cvitic, a 30-year-old woman with cervical cancer, underwent radical hysterectomy on 11 February 2002. She collapsed on 14 February with signs of hypovolaemic shock (haemoglobin 5.3 g/dL). Dr W. performed emergency lap…

oncologygeneral surgerydiagnosticmedicationheparin
WAhome2007-09-14

Inquest into the Death of Jones Coronial

9y · Male·Head injury (epidural haematoma with cerebral coning following craniotomy)

Dwayne Michael Jones, aged 9, had Trisomy 10, a rare congenital chromosomal disorder causing severe developmental delay and neurological abnormalities. On 11 April 2000, he fell from a computer desk and struck his head. …

general practiceemergency medicinediagnosticdelayparacetamol
QLDhospital2007-08-10

Tang, Shannon Sheng Wen

21y · Male·multi-organ failure due to septicaemia of mixed respiratory (bronchopneumonia) a…

Shannon Tang, a 21-year-old from Singapore with severe obesity (BMI 52) and multiple comorbidities including sleep apnoea, underwent elective laparoscopic gastric bypass surgery performed by Dr F.. He died on day 7 post-…

bariatric surgerygeneral surgerycommunicationdiagnosticvancomycin
SAhospital2007-06-29

Coroner's Finding: COCKBURN Michael Philip

40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)

Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anae…

psychiatryemergency medicinemedicationcommunicationhaloperidol
SAcommunity2007-06-08

Coroner's Finding: COOKE Rowan Douglas

37y · Male·dehydration/heat-related death

A 37-year-old man died from dehydration and heat-related illness after collapsing in a sweat lodge during a vision quest ceremony in remote South Australia. He remained unconscious after removal from the lodge, but the g…

emergency medicineintensive carediagnosticdelay
QLD2007-05-16

Davis, Jodie Maree

24y · Female·hypoxic brain damage due to cardiac arrest due to hanging

Jodie Maree Davis, aged 24, died by suicide in Townsville Correctional Centre in May 2002. She had a long history of self-harm dating from age 15, including multiple suicide attempts, and was assessed as high suicide ris…

psychiatrypsychologysystemcommunication
QLDhospital2007-04-05

Smith, Arthur Lawrence

75y · Male·Acute cardiac failure due to mitral valve disease (surgically treated)

Arthur Lawrence Smith, 75, underwent successful mitral valve repair and coronary artery bypass grafts at TPCH on 2 August 2004 and was discharged 5 days later. On 19 August, his wife called TPCH reporting acute shortness…

cardiothoracic surgeryemergency medicinecommunicationdiagnosticadrenaline
QLDhome2007-03-22

Dee, Fiona Jane

32y · Female·Hypoxic brain injury due to a combination of factors arising from subdural haema…

A 32-year-old fit and healthy woman died from hypoxic brain injury following complications of spinal anaesthesia for caesarean section. She developed a subdural haematoma (rare complication) and persistent post-dural pun…

obstetricsanaesthesiacommunicationdiagnosticcarbamazepine
WAhospital2006-12-05

Inquest into the Death of Steele

63y · Male·ruptured abdominal aortic aneurysm

Norman Eric Keith Steele, 63 years old, collapsed at work on 28 May 2004 and was transported to Merredin District Hospital at 9:10am with a presenting complaint of severe abdominal pain (9/10) radiating to his back, dizz…

emergency medicinegeneral practicediagnosticdelayhyoscine butylbromide
NThospital2006-11-10

Inquest into the death of Wendy Walangitj Garmu

45y · Female·hypoxic brain injury following hemopneumothorax resulting from a stab wound to t…

Aboriginal woman stabbed in October 2004, discharged from hospital after initial stab wound assessment without chest X-ray or admission for observation. Wound to posterior chest was explored and stitched by Dr W. but pne…

emergency medicinesurgerydiagnosticprocedural
SAhospital2006-09-25

Coroner's Finding: McCARTHY Elly Sarahnia

13y · Female·cerebral oedema and infarction secondary to extensive subdural empyema

Elly McCarthy, a 13-year-old girl, died from cerebral oedema and infarction secondary to subdural empyema. She developed fever, headache and neurological symptoms on 24 January 2004 and was initially seen at a GP and Noa…

paediatricsemergency medicinediagnosticcommunicationtrimethoprim
SAhospital2006-09-25

Coroner's Finding: McLEOD Peter Malcholm

28y · Male·Acute Dopamine Imbalance Syndrome

A 28-year-old man with first-episode psychosis presented with command auditory hallucinations after a motor vehicle accident. An EEG ordered to exclude organic causes showed very abnormal findings suggestive of partial s…

psychiatryneurologycommunicationdiagnosticrisperidone
QLDmental health2006-09-08

Robinson, Terence James

54y · Male·Global cerebral hypoxic injury due to or as a consequence of status epilepticus

Terence James Robinson, 54, died from status epilepticus causing global cerebral hypoxic injury after 16 days at Belmont Private Hospital. He was admitted following a violent altercation with police and attempted suicide…

psychiatryneurologydiagnosticcommunicationparoxetine
NT2006-09-08

Inquest into the death of Hector Martin

36y · Male·Cerebrovascular accident (stroke) - massive intracranial haemorrhage

An Aboriginal man with chronic alcoholism and cirrhosis died from a massive stroke (cerebrovascular accident) while in prison custody. He presented with non-specific symptoms including vomiting on 9 March 2005 and was pl…

general practicecorrectional healthcommunicationsystemdiazepam
SAhospital2006-08-22

Coroner's Finding: DENNIS Jessica-Lee

16y · Female·consequences of acute asthma with hypoxic encephalopathy

Jessica-Lee Dennis, aged 16, died from acute asthma with hypoxic encephalopathy on 7 May 2004. She presented with progressive nocturnal cough and wheezing over six weeks starting September 2001, with significant family h…

general practicerespiratory medicinediagnosticcommunicationsalbutamol
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