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NSWhospital2019-09-04

Inquest into the death of Ivan METCALFE

82y · Male·Complications associated with advanced chronic lung disease

Ivan Metcalfe, aged 82, died of complications from advanced chronic lung disease while in prison custody. He had multiple comorbidities including diabetes, ischaemic cardiovascular disease, and atrial fibrillation. He wa…

respiratory medicinecardiologycommunicationsystemantibiotics
WAhospital2019-08-30

Inquest into the Death of James Ronald CHI

69y · Male·Chronic obstructive pulmonary disease and coronary artery atherosclerosis

James Ronald Chi, aged 69, died from chronic obstructive pulmonary disease and coronary artery atherosclerosis at Broome Hospital. He was an involuntary mental health patient with treatment-resistant bipolar disorder and…

psychiatryemergency medicineclozapine
WA2019-08-20

Inquest into the Death of Judy Sonia BOLTON

44y · Female·acute myocardial infarction due to coronary thrombosis

A 44-year-old Aboriginal woman died from acute myocardial infarction (heart attack) due to coronary thrombosis while in custody at Bandyup Women's Prison in Western Australia. She had multiple cardiovascular risk factors…

cardiologyemergency medicinediagnosticsystemmetoprolol
VIChospital2019-08-01

Finding into death of Tyla Jade Hovenbitzer

18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…

An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…

paediatricsgeneral practicesystemdelaytemazepam
WAhospital2019-07-22

Inquest into the Death of Arthur James BONNEY

59y · Male·ischaemic heart disease in the context of acute-on-chronic kidney failure associ…

Arthur James Bonney, a 59-year-old prisoner with advanced cardiac disease, chronic kidney disease, and diabetes, underwent a CT scan with iodinated contrast on 30 July 2015 at Fiona Stanley Hospital. Critical failures oc…

radiologycardiologydiagnosticproceduraliodinated contrast medium
WA2019-06-19

Inquest into the Death of Malcolm Patrick O'DRISCOLL

66y · Male·acute myocardial infarction on a background of atherosclerotic cardiovascular di…

Malcolm Patrick O'Driscoll, a 66-year-old life-sentenced prisoner, died on 15 April 2017 at Acacia Prison from acute myocardial infarction on a background of severe atherosclerotic cardiovascular disease. He had been imp…

cardiologyvascular surgery
QLDcommunityPodcast2019-06-12

Brown, Holly Winta

17y · Female·Arrhythmia due to myocardial scarring secondary to past myocarditis, possibly fr…

Holly Brown, 17, died of fatal cardiac arrhythmia from undiagnosed heart scarring likely due to childhood rheumatic fever. She collapsed at a regional mass gathering event (2000+ attendees) in remote Laura, Queensland. C…

emergency medicinegeneral practicesystemcommunicationadrenaline
WAhospital2019-05-31

Inquest into the Death of Aurelio Monterlegre CRUZ

80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…

Aurelio Monterlegre Cruz, an 80-year-old man with complex medical conditions including chronic renal failure, ischaemic heart disease, diabetes, and COPD, died of bronchopneumonia complicating terminal palliative care wh…

nephrologypalliative carecommunicationdelayinsulin
WAmental health2019-05-22

Inquest into the Death of Pamela Edith ASHLEY

64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…

A 64-year-old woman with bipolar disorder, severe obstructive sleep apnoea, obesity and diabetes presented with acute psychotic relapse following stress and sleep deprivation. Initially admitted to ED where she was sedat…

psychiatryemergency medicinecommunicationsystemchlorpromazine
WAmental health2019-05-22

Inquest into the Death of Christopher John DEBNAM

40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…

Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensat…

psychiatryrespiratory medicinediagnosticcommunicationhaloperidol
VICcommunity2019-05-15

Finding into death of Desmond John Watson

65y · Male·Neck trauma and severe ischaemic heart disease in the setting of immersion

A 65-year-old experienced kneeboarder died from neck trauma and severe ischaemic heart disease following immersion at a surf competition. He fell from his board during the B Grade Final in challenging conditions at Gunna…

forensic medicineemergency medicinesystem
VIChospital2019-05-10

Finding into death of Simon Smith

22y · Male·acute blood loss from incised injuries to left forearm

Simon Smith, a 22-year-old with end-stage renal failure requiring dialysis and complex comorbidities, died by suicide during hospitalization. Despite multiple psychiatric assessments finding he had capacity to make treat…

psychiatrynephrologycommunicationsystemtemazepam
TAShospital2019-04-18

Coroner's Finding: Kenney, Margaret Patricia

83y · Female·upper gastrointestinal bleed with haemodynamic compromise following anticoagulat…

Margaret Patricia Kenney, 83, died from upper gastrointestinal bleeding complicated by cardiac arrest while anticoagulated for atrial fibrillation. She had been diagnosed with gastro-oesophageal reflux disease (GORD) in …

general medicinecardiologymedicationdiagnosticpantoprazole
VICcommunity2019-04-03

Finding into death of Frank Hulland

77y · Male·Chest and pelvic injuries sustained in a farming incident

A 77-year-old farmer died from chest and pelvic injuries sustained in a farm machinery incident. Mr Hulland was operating a Ford utility with an attached hydraulic trailer in low gear without a driver, a common practice …

forensic medicinegeneral practicesystem
TAS2019-03-29

Coroner's Finding: Best, Christopher Mark

58y · Male·Traumatic pulmonary artery rupture as a result of a motorcycle crash

A 58-year-old man died from traumatic pulmonary artery rupture following a motorcycle crash into a farm gate at low speed (~30km/h). He had a history of neurocardiogenic syncope with recurrent presyncope and palpitations…

pathologycardiology
NSWhospital2019-03-22

Inquest into the death of Patrick THOMAS

52y · Male·Intestinal failure/sepsis arising from venous ischemia as a result of superior m…

Patrick Thomas, a 52-year-old man, died from intestinal failure and sepsis following an accidental division of the superior mesenteric vein (SMV) during laparoscopic surgery for colon cancer at Kareena Private Hospital o…

colorectal surgeryintensive carecommunicationsystem
TAScommunity2019-03-08

Coroner's Finding: Paraskevas, Odissefs

56y · Male·pulmonary thromboembolism due to left deep vein thrombosis

A 56-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis. He presented to his GP on 20 January 2017 with persistent dyspnoea and chest pain following a 22-hour flight to Greece and respirat…

general practicecardiologydiagnosticdelay
NSWhospital2019-03-01

Inquest into the death of Stephen Kline

51y · Male·Pulmonary thromboemboli due to deep vein thrombosis on a background of a leg bur…

Stephen Kline, a 51-year-old Aboriginal man, died from pulmonary thromboembolism due to deep vein thrombosis following a leg burn wound sustained when NSW Police deployed a taser during a confrontation on 8 March 2016. H…

plastic and reconstructive surgerypsychiatrydiagnosticsystemheparin
VIChospital2019-02-05

Finding into death of Eliza Gill

18y · Female·Colchicine toxicity

An 18-year-old female died from colchicine toxicity after intentional overdose of her father's medications during a mental health crisis. She ingested approximately 10-15g of colchicine (dose 0.25mg/kg), below the guidel…

emergency medicineintensive carediagnosticsystemcolchicine
VICcommunity2019

Finding into death of Gregory Mark Hulands

53y · Male·Mechanical asphyxia in the setting of a motor vehicle incident (driver)

A 53-year-old truck driver died from mechanical asphyxia when his vehicle left a rural highway near a right-hand bend with poor road design. Toxicological testing revealed cannabis at 59 ng/mL (elevated concentrations). …

forensic medicineemergency medicinecannabis
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