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QLDhospital2016-02-29

Mr B - Non-inquest findings

84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…

An 84-year-old man with multiple comorbidities was prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed,…

cardiologyhaematologymedicationcommunicationrivaroxaban
VIChome2016-02-17

Finding into death of Lorraine Mary Bartolome

73y · Female·Exsanguination from ruptured varicose vein right lower leg

A 73-year-old woman died from exsanguination following rupture of a varicose vein on her right lower leg while on anticoagulation therapy (dabigatran) for atrial fibrillation. She called emergency services at 1:22 am on …

emergency medicinecardiologycommunicationsystemdabigatran
QLDhospital2016-02-17

Dickinson, Rick Dudley

55y · Male·Cardiac tamponade due to ruptured aortic dissection (Type A) against a backgroun…

Rick Dickinson, a 55-year-old man, presented to St Andrew's War Memorial Hospital after experiencing severe central chest pain and lower back pain with numbness at the gym. The treating senior doctor failed to adequately…

emergency medicinepathologydiagnosticcommunicationmorphine
VIChome2016

Finding into death of Alexander James McCulloch

35y · Male·Complications of morbid obesity in a man with cardiomegaly and schizophrenia

Alexander McCulloch, a 35-year-old man with schizophrenia, morbid obesity (BMI 45), and cardiomegaly, was found dead in bed. Autopsy attributed death to complications of morbid obesity with cardiomegaly and schizophrenia…

psychiatrygeneral practicecommunicationsystemfluphenthixol decanoate
NSWhospital2015-12-02

Inquest into the death of Dr Peter Domachuk

33y · Male·presumed fatal cardiac arrhythmia in the presence of coronary artery atheroscler…

Dr D., a 33-year-old physicist, was admitted to Hornsby Hospital on 27 December 2012 with abdominal pain, nausea, vomiting and joint pain. His presentation included hypotension (97/61), tachycardia (116/min), hyponatraem…

emergency medicinegeneral medicinecommunicationsystemdiclofenac
VIChospital2015-12-02

Finding into death of Khodr El Mustapha

77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…

A 77-year-old man with iron deficiency anaemia and underlying ischaemic heart disease died from anaphylaxis following iron polymaltose infusion. Critical clinical lessons: (1) IV iron should only be administered after or…

emergency medicinehaematologydiagnosticproceduraliron polymaltose
VIC2015-12-01

Finding into death of James Willian Steele

63y · Male·Hypotensive and atherosclerotic heart disease

A 63-year-old male prisoner with Type II diabetes, hypertension, obesity and coronary atherosclerosis died of cardiac arrhythmia while engaged in farm work at a minimum-security prison. Dr L. provided acceptable diabetes…

general practicegeneral medicinedocumentationcommunicationlercanidipine
NSWhospital2015-11-16

Inquest into the death of Ivy Dwyer

18y · Female·Severe cardiogenic shock caused by myocarditis as a consequence of an unknown vi…

Ivy Dwyer, 18, died from viral myocarditis causing cardiogenic shock. She presented over weeks with progressive non-specific symptoms (nausea, vomiting, fatigue, cough) consistent with viral illness. A locum GP diagnosed…

general practiceemergency medicinediagnosticcommunicationloperamide
QLD2015-11-04

Spence, John Michael

51y · Male·Combined effects of atherosclerotic cardiovascular disease and seizure activity …

John Spence, a 51-year-old man with a history of seizures, alcoholism, and severe coronary artery disease, died in a prison health centre following a seizure episode. He had ingested an extraordinarily high level of caff…

emergency medicinecardiologydiagnosticcommunicationcaffeine
TAShome2015-10-08

Coroner's Finding: Mundy, Kaylene Louise

40y · Female·acute right-sided congestive heart failure (cor pulmonale) resulting from intrav…

Kaylene Mundy, aged 40, died from acute right-sided congestive heart failure (cor pulmonale) caused by intravenous injection of crushed alprazolam tablets. She had a long history of opioid and polysubstance abuse, with r…

addiction medicineemergency medicinealprazolam
NSWhome2015-09-26

Inquest into the death of Kerryn Foale

22y · Female·ventricular fibrillation resulting from hypertrophic cardiomyopathy when her imp…

22-year-old woman with hypertrophic cardiomyopathy died from ventricular fibrillation when her implantable cardioverter defibrillator (ICD) failed to terminate the arrhythmia due to lead insulation failure caused by chro…

cardiologycardiothoracic surgerysystem
SAhospital2015-09-22

Coroner's Finding: HEWLETT Betty Lorraine

92y · Female·community acquired pneumonia on a background of end stage chronic obstructive ai…

Mrs Betty Hewlett, 92, died of community-acquired pneumonia on a background of end-stage COAD. She was admitted to hospital in late December 2012 with health deterioration and malnutrition (38kg). She developed acute psy…

psychiatrygeneral medicineprednisolone
VICcommunity2015-08-21

Finding into death of Mohamed Hamza

40y · Male·coronary artery atherosclerosis

40-year-old male with hypercholesterolaemia presented to general practice with new-onset central chest pain radiating to neck and arm, plus shortness of breath. The practice nurse obtained an ECG and recorded the radiati…

general practicecardiologydiagnosticcommunicationatorvastatin
NT2015-08-14

Inquest into the death of Perry Langdon

59y · Male·idiopathic dilated cardiomyopathy (probably alcohol related)

A 59-year-old Aboriginal man died of idiopathic dilated cardiomyopathy in a Darwin police watch house following arrest for the minor offence of drinking in a designated public place. He had severe, documented cardiac dis…

emergency medicinecardiologysystemcommunication
TAShome2015-07-29

Coroner's Finding: Mr J

76y · Male·contact range gunshot wound to the head, self-inflicted

A 76-year-old man with bilateral leg amputations maintained independent living until presenting with syncope. Hospital evaluation identified ischemic heart disease; he refused angiography and was discharged. Post-dischar…

cardiologyemergency medicine
QLDhospital2015-07-28

Mills, Stephen John

57y · Male·Head injury from fall; with coronary atherosclerosis and complete heart block wi…

A 57-year-old man with bipolar disorder died from head injury following a fall at Toowong Private Hospital. Critical failures in falls risk management were identified: no formal falls risk assessment was completed on adm…

psychiatryneurosurgerysystemcommunicationseroquel xr
NSWhospital2015-07-27

Inquest into the death of Lynette Maree YOUNG

46y · Female·Shock following interferon alpha treatment following removal of a melanoma

Lynette Young, 46, died of shock secondary to pericarditis with cardiac tamponade following interferon alpha treatment for melanoma. She presented with chest pain to Dubbo Base Hospital where multiple clinical failures o…

oncologycardiologydiagnosticcommunicationinterferon alpha
QLDhospital2015-07-27

KS - Non-inquest findings

69y · Male·Intracerebral haemorrhage due to sepsis (Staphylococcus aureus bacteraemia), com…

A 69-year-old man with a history of myocardial infarction and atrial fibrillation presented to a rural hospital with fever, lethargy, tachycardia and elevated troponin. The treating doctor diagnosed NSTEMI based on the e…

emergency medicinecardiologydiagnosticmedicationrivaroxaban
VIChome2015-07-24

Finding into death of James Stewart Dougan

32y · Male·Mixed drug toxicity (codeine, methadone, alprazolam, diazepam) in a man with cor…

James Dougan, 32-year-old man with longstanding polysubstance abuse, died from mixed drug toxicity (codeine, methadone, alprazolam, diazepam) complicated by severe coronary artery atherosclerosis. He engaged in prescript…

general practiceaddiction medicinemedicationcommunicationalprazolam
SAhospital2015-07-17

Coroner's Finding: ASTON Marjorie Irene

86y · Female·right subdural haematoma due to blunt head trauma with contributing excessive wa…

An 86-year-old woman died from subdural haematoma following a minor head injury, complicated by excessive warfarin anticoagulation. She was started on warfarin by a cardiologist on 19 December 2012 for atrial fibrillatio…

cardiologygeneral practicecommunicationsystemwarfarin
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