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VIC2014-10-27

Finding into death of Kyle William Vassil

12y · Male·Unascertained in the setting of immersion; involuntary inhalation of water after…

Kyle Vassil, a 12-year-old competent swimmer, died by submersion in a cold, murky dam at a school camp. After 4-5 minutes of swimming, Kyle experienced acute difficulty, likely related to panic, anxiety, possible asthma,…

general practicecardiologysystemcommunication
VIChospital2014-10-02

Finding into death of Penrin John Maxworth Halliday

60y · Male·Ischaemic gut secondary to superior mesenteric artery dissection complicating in…

A 60-year-old man with severe coronary artery disease presented with acute myocardial infarction, requiring emergency stenting and subsequent bypass surgery. An intra-aortic balloon pump (IABP) was inserted for haemodyna…

cardiologycardiothoracic surgery
VIChospital2014-09-30

Finding into death of Iman Kassis

46y · Female·hemopericardium secondary to dissection of the thoracic aorta

Iman Kassis, a 46-year-old woman with Ehlers-Danlos Syndrome Type 4 and known severe aortic regurgitation with dilated ascending aorta, presented to the ED on 8 October 2008 with sudden-onset severe throat pain, bradycar…

emergency medicinecardiologydiagnosticdocumentationflecainide
QLDhospital2014-09-03

A Patient - Non-inquest findings

66y · Male·legionella pneumophila pneumonia

A 66-year-old man with multiple myeloma undergoing chemotherapy died from legionella pneumonia acquired from the Wesley Hospital water system. He was immunocompromised due to chemotherapy and corticosteroids, making him …

infectious diseasesoncologysystemcommunicationchemotherapy
QLDhospital2014-09-01

SG - Non-inquest findings

68y · Female·Haemorrhage secondary to right subclavian artery lacerations sustained during ce…

A 68-year-old woman died from massive blood loss following inadvertent puncture of the right subclavian artery during central venous line insertion. The anaesthetist used anatomical landmarks without ultrasound after an …

anaesthesiageneral surgeryheparin
NSWmental health2014-08-08

Inquest into the death of Josephine LAMBERT

44y · Female·natural causes, possibly a cardiac arrhythmia

Josephine Lambert, 44-year-old woman with treatment-resistant schizophrenia, died at Cumberland Hospital on 28 July 2011. She was found unconscious in the hallway and could not be resuscitated. The autopsy initially sugg…

psychiatryforensic medicineclozapine
VIChospital2014-07-28

Finding into death of Glen David Kingsun

42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…

Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…

general practiceemergency medicinemedicationcommunicationverapamil
NT2014-07-21

Inquest into the death of Ryan Smiler

39y · Male·cardiac arrest caused by alcoholic cardiomyopathy

Ryan Smiler was a 39-year-old Aboriginal man who died from cardiac arrest caused by alcoholic cardiomyopathy while in custody at Darwin Correctional Centre. He had a long history of alcohol abuse, hypertension, and heart…

cardiologyemergency medicinedelaywarfarin
NSWcommunity2014-07-18

Inquest into the death of Pat MORENA

24y · Male·Combination of factors including methylamphetamine toxicity, physical exertion, …

Pat Morena, a 24-year-old drug dealer under police surveillance, died during restraint in the prone position after being apprehended on suspicion of drug offences. He was acutely intoxicated with high-concentration methy…

forensic medicinetoxicologysystemmethamphetamine
VIChospital2014-07-14

Finding into death of Mary Una Barnett

71y · Female·Diffuse Lymphoid Malignancy

Mary Una Barnett, a 71-year-old woman in custody at Dame Phyllis Frost Centre, died from diffuse lymphoid malignancy (high-grade lymphoma) discovered shortly before her death. She had extensive comorbidities including ch…

cardiologynephrologysystemdelay
NSWhospital2014-07-11

Inquest into the death of Toni Ann PEADON

52y · Female·laceration of the superior vena cava and right atrium during defibrillator lead …

A 52-year-old woman with a history of syncope and mitral valve prolapse, who had an implanted defibrillator, underwent a percutaneous laser lead extraction procedure at Westmead Hospital to remove and replace defective l…

cardiologycardiothoracic surgerysystemdelay
QLDhospital2014-06-20

O - Non-inquest findings

82y · Male·hypoxic-ischaemic encephalopathy due to cardiac arrest as a result of fractured …

An 82-year-old man died from hypoxic-ischaemic encephalopathy following perioperative cardiac arrest during ankle fracture surgery. The anesthetist failed to recognise clinical deterioration, did not intubate despite sig…

anaesthesiaorthopaedic surgerydiagnosticproceduralbisoprolol
VIChospital2014-06-05

Finding into death of Constandia Petzierides

74y · Female·haemothorax secondary to dissecting thoracic aorta

Mrs Petzierides, a 74-year-old woman, presented to the emergency department with sudden-onset, severe left scapular pain radiating to the jaw, occurring shortly after midnight. She was assessed by an emergency medicine r…

emergency medicinecardiologydiagnosticcommunicationwarfarin
VICcommunity2014-06-03

Finding into death of Michael (Miroslav) Cicmil

44y · Male·Effects of fire and smoke inhalation

A 44-year-old male died from fire and smoke inhalation following a single-vehicle motor collision on a wet road at high speed (≥117 km/h) in a 60 km/h zone. He was driving under the influence of cannabis (THC 1 ng/mL), h…

forensic medicineemergency medicinecannabis
VIChospital2014-05-29

Finding into death of Lilian Olive Blanche McClurkin

61y · Female·Peritonitis due to anastomotic leak at gastrectomy site; pathological obesity as…

A 61-year-old woman with pathological obesity died from peritonitis secondary to anastomotic leak following laparoscopic sleeve gastrectomy. The procedure itself was appropriate for her failed previous lap band surgeries…

bariatric surgerygeneral surgerycommunicationsystemtramadol
NTcommunity2014-05-27

Inquest into the death of Benjamin Wilton

29y · Male·severe burns sustained in motor vehicle fire following collision

29-year-old Benjamin Wilton was killed in a horrific car fire following a rear-end collision with a vehicle driven by 67-year-old Robert Spencer on a Darwin highway. Spencer had suffered a stroke in 2003 with residual co…

neurologycardiologydiagnosticsystem
NThospital2014-05-15

Inquest into the death of Eric Lewis Wobona

55y · Male·Cardiac hypertrophy with significant conditions contributing: coronary artery at…

Eric Lewis Wobona, a 55-year-old Aboriginal man with extensive cardiovascular risk factors including congestive cardiomyopathy, coronary artery disease, hypertension, diabetes, and previous amputation, died of acute hear…

cardiologyemergency medicineaspirin
VICaged care2014-05-14

Finding into death of Norma Alice Bensley

92y · Female·Ischaemic heart disease in the setting of inappropriate administration of antihy…

Norma Bensley, a 92-year-old aged care resident, died from ischaemic heart disease after being inadvertently administered another resident's antihypertensive medications. A newly qualified nurse administered the wrong me…

geriatric medicinegeneral practicemedicationsystemantihypertensive medications
VICaged care2014-03-31

Finding into death of Margaret Lurline Martyr-Paterson

87y · Female·Multiple injuries with ischaemic heart disease, antecedent cause being recent fa…

87-year-old Margaret Martyr-Paterson, a low-care resident with dementia and ischaemic heart disease at Shoreham House aged care facility, fell from her bedroom window on 17 February 2010 and died 11 days later from multi…

geriatric medicinegeneral practicecommunicationsystem
VIC2014-03-06

Finding into death of Geoffrey Ashton

78y · Male·Ischemic heart disease

Geoffrey Ashton, a 78-year-old with significant ischemic heart disease, died in the foyer of Croydon Police Station on 17 December 2011. Stress from an altercation over disabled parking at a nearby church likely triggere…

cardiologypathologydelayprocedural
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