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SAhospital2006-08-18

Coroner's Finding: CAMPANELLA Cosmo Joseph

20y · Male·anoxic brain injury following cardio-respiratory arrest caused by hypoxia result…

A 20-year-old male died from anoxic brain injury following cardiac arrest caused by hypoxia resulting from tracheostomy tube occlusion. After motor vehicle trauma, he underwent surgery and was eventually transferred to a…

intensive careneurosurgerysystemcommunicationmannitol
SAhospital2006-05-19

Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…

77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural ta…

cardiologycardiothoracic surgerydiagnosticproceduralramipril
SAhospital2006-05-18

Coroner's Finding: PAHL-CADMAN Emma Rose

20y · Female·cardiac dysrhythmia/arrest in a 20 year old Down's Syndrome female following abd…

A 20-year-old woman with Down syndrome and Eisenmenger syndrome (cyanotic heart disease with ventricular septal defect) was admitted with abdominal obstruction. After appropriate diagnostic workup, laparotomy was perform…

general surgeryanaesthesiadiagnosticcommunication
SAhospital2006-05-12

Coroner's Finding: MARTIN Kirsten Lee

24y · Female·multi organ failure due to meningococcal septicaemia

24-year-old woman presented to ED with fever (40.1°C), headache, myalgia and mild photophobia. RMO Dr R., relatively inexperienced (5 weeks in Australia), examined her thoroughly but focused on excluding meningitis throu…

emergency medicineinfectious diseasesdiagnosticcommunication
SAcommunity2006-02-22

Coroner's Finding: SINCLAIR-SPAAN Christopher James

21y · Male·Closed head injury and retroperitoneal and pelvic haematoma due to fractured pel…

A 21-year-old man died from massive internal bleeding into the pelvis and retroperitoneum following a motor vehicle collision with a stobie pole in rural South Australia. He was trapped for over 2 hours before extricatio…

intensive caretrauma surgerycommunicationsystem
QLDmental health2006-02-03

Muckan, David Jones

49y · Male·Obstructive sleep apnoea, contributed to by the sedating effects of therapeutic …

David Muckan, a 49-year-old man with schizophrenia, was admitted to a psychiatric unit in April 1998 with suspected obstructive sleep apnoea (OSA). He was sedated with benzodiazepines (Midazolam, Diazepam) and other psyc…

psychiatryrespiratory medicinemedicationmonitoringthioridazine
SAhospital2006-01-12

Coroner's Finding: EVANS Shaun Michael

22y · Male·Mixed Diflunisal and Buproprion (Zyban) toxicity

A 22-year-old man presented to Royal Adelaide Hospital's Emergency Department after taking approximately 110 Zyban (bupropion) tablets as a suicide attempt. Unknown to treating staff, he had also ingested a potentially l…

emergency medicinetoxicologydiagnosticcommunicationbupropion
WAhospital2005-12-09

Inquest into the Death of Laura Marguerite Sinclair

31y · Female·Post-partum Haemorrhage associated with Amniotic Fluid Embolism and Uterine Hypo…

Laura Marguerite Sinclair, 31-year-old primigravida, died from post-partum haemorrhage associated with amniotic fluid embolism (AFE) and uterine hypotonia. She underwent emergency caesarean section for foetal distress at…

obstetricsanaesthesiadiagnosticcommunicationpethidine
WAhospital2005-11-25

Inquest into the Death of Waretini

46y · Male·Upper airway obstruction due to acute tonsillitis with laryngeal oedema and haem…

A 46-year-old man with acute tonsillitis complicated by upper airway obstruction died at Cunderdin District Hospital. He presented with severe pharyngitis on 5 September 2002, was admitted to Kellerberrin Memorial Hospit…

general practiceemergency medicinecommunicationsystempenicillin
SAhospital2005-11-10

Coroner's Finding: LAZOPOULOS Christopher

34y · Male·multi-organ failure with right-sided tension pneumothorax

A 34-year-old man with a ruptured spleen and fractured ribs presented to the Emergency Department on multiple occasions with abdominal and chest pain. He was discharged on 28 February, 5 March and 6 March without admissi…

emergency medicineintensive carediagnosticsystem
NT2005-10-31

Inquest into the death of Angus Lawrence

25y · Male·acute heat stroke

Trooper Angus Lawrence, a 25-year-old soldier, died from acute heat stroke on 10 November 2004 during a military training exercise at Mount Bundey, NT. He collapsed during a patrol and despite rapid evacuation and intens…

paramedicineoccupational and environmental healthdiagnosticcommunication
WAhospital2005-09

Inquest into the Death of Maria Donatelli

72y · Female·Peritonitis due to perforated diverticulum in transverse colon

Maria Donatelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially managed conservatively with a provisional diagnosis of pancreatitis…

general surgeryemergency medicinediagnosticcommunicationtramadol
SAhospital2005-08-30

Coroner's Finding: O'BRIEN Barbara Ann

57y · Female·right bronchopneumonia following hypoxic brain damage secondary to cardiac arres…

A 57-year-old woman with chronic schizophrenia and non-insulin dependent diabetes was admitted to a psychiatric ward after detention under the Mental Health Act. She was found in cardiac arrest on 8 December 2001 and suf…

psychiatryemergency medicinediagnosticcommunicationclozapine
NTprison2005-08-26

Inquest into the death of Warren Maminyamanja

34y · Male·Septicaemia resulting from Melioidosis

Warren Maminyamanja, a 34-year-old Aboriginal man, died from melioidosis septicaemia on 13 June 2004 whilst in custody at Darwin Correctional Centre. Clinical assessment for melioidosis was not considered, though expert …

emergency medicineintensive caresystemdelayibuprofen
SAhospital2005-06-02

Coroner's Finding: HUTCHINSON Matthew

0y · Male·cardiogenic shock and neonatal encephalopathy

Matthew Hutchinson, born at 1 day of age at Flinders Medical Centre, died from cardiogenic shock and neonatal encephalopathy. While obstetric care was appropriate, neonatal care was significantly deficient. Critical fail…

neonatologyobstetricsproceduralcommunicationphenobarbital
SAhospital2005-05-24

Coroner's Finding: WALLACE-MOHLMANN Candice Mackenzie

30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…

Candice Mackenzie Wallace-Mohlmann, a 30-year-old woman with chronic schizophrenia and substance abuse history, died from hypoxic brain injury caused by self-injection of vecuronium and atropine obtained from a hospital …

psychiatryemergency medicinediagnosticmedicationvecuronium
QLDhospital2005-05-04

Robinson, Jacinta Kate

7y · Female·cardiac tamponade due to total parenteral nutrition fluid leakage into the peric…

A 7-year-old girl with spina bifida died from cardiac tamponade caused by total parenteral nutrition (TPN) fluid leaking into the pericardial sac via a central venous line inserted during bowel obstruction surgery. Clini…

paediatric surgeryanaesthesiadiagnosticcommunicationtotal parenteral nutrition
WAcommunity2005-05

Inquest into the Death of Adam David McKay

31y · Male·Pulmonary thromboembolism arising from deep vein thrombosis

Adam David McKay, a 31-year-old geologist, died from pulmonary thromboembolism arising from deep vein thrombosis on 23 January 2003. He had recently completed extensive long-haul flights to West Africa and returned on 13…

general practiceemergency medicinediagnosticcommunication
NThospital2005-04-06

Inquest into the death of Peter Wiryal

48y · Male·Cerebrovascular Accident (stroke) caused by subdural haemorrhage, which resulted…

Peter Wiryal, 48, was struck by a white van driven by an intoxicated Daniel Johnson along George Crescent, Fannie Bay at approximately 12:30am on 4 April 2003. He was discharged from Royal Darwin Hospital on 4 April afte…

emergency medicineneurosurgerydiagnosticcommunicationalcohol
SAhospital2004-11-18

Coroner's Finding: PEDDEY Ross Dudley

63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…

A 63-year-old man died from pneumonia complicating anoxic brain injury following a post-operative haemorrhage from the inferior epigastric artery during ileostomy closure surgery. The critical failure was a 2.5-hour dela…

colorectal surgerygeneral surgerydiagnosticdelaywarfarin

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