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VIChospital2025-04-17

Finding into death of Graeme William Dimsey

62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…

A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…

orthopaedic surgeryinfectious diseasesdiagnosticproceduralceftriaxone
VIChospital2025-03-12

Finding into death of Robin Albert Banks

90y · Male·Pneumonia complicating injuries sustained in a motor vehicle incident

A 90-year-old man died from pneumonia following injuries sustained in a motor vehicle collision. He had multiple reportable medical conditions including atrial fibrillation, coronary artery disease, chronic kidney diseas…

general medicinegeriatric medicinecommunicationsystemdigoxin
VIChospital2025-03-03

Finding into death of Caroline Anne McCormack

74y · Female·Infective exacerbation of chronic obstructive airways disease in the setting of …

Caroline McCormack, 74, died from infective exacerbation of chronic obstructive airways disease following a medication administration error where pregabalin was erroneously included in her Webster-pak despite being cease…

general practicepalliative caremedicationsystempregabalin
WAhome2025-02-12

Inquest into the Death of Kimberley Michael VULICH

64y · Male·complications in association with thermal injuries in a man with underlying chro…

Kim Vulich, a 64-year-old man with decompensated liver cirrhosis from chronic alcohol use, developed hepatic encephalopathy and cognitive impairment including possible Korsakoff syndrome. Despite SAT guardianship orders …

general medicinegeriatric medicinecommunicationdelay
VIChome2025-01-20

Finding into death of Kim Marie Bartolo

47y · Female·Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol…

Kim Bartolo, a 47-year-old woman with depression, anxiety, alcohol use disorder and chronic conditions, died from mixed drug toxicity involving multiple prescription medications. She was admitted to Brunswick Private Hos…

psychiatryorthopaedic surgerycommunicationmedicationvenlafaxine
TAShospital2025-01-20

Coroner's Finding: Lowe, Wayne Anthony

58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humeru…

Wayne Anthony Lowe, aged 58, died of multiorgan failure due to sepsis following repeated humeral fractures sustained in falls. He was admitted with a right proximal humeral fracture from an intoxicated fall, discharged a…

orthopaedic surgerygeneral medicinesystemdelay
NSW2024-12-03

Inquest into the death of Simon Cartwright

41y · Male·Septicaemia secondary to chronic peptic ulcer disease

Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer history diagnosed in November 2020 and sho…

psychiatrygastroenterologydiagnosticsystempantoprazole
QLDhospital2024-11-20

Non-inquest findings into the death of Mr W

82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis

An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …

general medicinegeriatric medicinediagnosticcommunicationendone 2.5mg
WA2024-11-15

Inquest into the death of Kingsley Dean Garlett

32y · Male·ligature compression of the neck (hanging) in a man with methadone and methylamp…

Kingsley Garlett, aged 32, died by hanging in a maximum security prison cell on 31 July 2022. The evidence indicates his death was an impulsive response to relationship conflict with his partner revealed through prison p…

psychiatrypsychologysystemdelaymethadone
WAhospital2024-11-13

Inquest into the death of Chloe Grace Tupper

31y · Female·organ failure due to anorexia nervosa

Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…

psychiatrypaediatricssystemcommunicationmirtazapine
NSW2024-10-31

Inquest into the death of AB

34y · Male·Incision/stab wound to the neck

A 34-year-old male remandee died by self-inflicted neck wound while in custody at Metropolitan Remand and Reception Centre. He had been discharged from Risk Intervention Team management following a self-harm incident 7 d…

psychiatryemergency medicinediagnosticsystem
TAShospital2024-10-18

Coroner's Finding: Long, Leonard

73y · Male·subdural haematoma from fall

Leonard Athol Long, a 73-year-old on warfarin for mechanical mitral valve replacement, fell twice during hospitalization for urinary tract infection. He was on SMZ-TMP antibiotics, which interact significantly with warfa…

general medicineemergency medicinediagnosticsystemwarfarin
TAShospital2024-10-11

Coroner's Finding: Vieth, Karl Heinz

92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…

A 92-year-old man with complex cardiac history was admitted to Royal Hobart Hospital with chest pain and atrial fibrillation. He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, …

general medicineemergency medicinesystemdelaymelatonin
TAShospital2024-10-10

Coroner's Finding: Hill, James Fredrick

74y · Male·small intestinal ischaemia caused by aortic atherosclerosis

A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clea…

emergency medicineorthopaedic surgerydiagnosticcommunication
WAhospital2024-09-24

Inquest into the death of Raymond Sydney CHEEK

89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…

Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarin…

emergency medicineendocrinologymedicationsystemryzodeg insulin
TAShospital2024-09-12

Coroner's Finding: Chapman, Jane Ann

74y · Female·Post-operative exacerbation of delirium and terminal functional deterioration du…

Jane Ann Chapman, 74, presented to hospital with delirium, fever and suspected urinary tract infection. She fell from an Emergency Department trolley bed, sustaining a neck of femur fracture requiring surgery. Post-opera…

emergency medicineorthopaedic surgeryproceduralsystem
VIChome2024-08-28

Finding into death of Laurence John Cox

Sodium nitrite toxicity

A 63-year-old man with a history of depression, anxiety, and chronic medical conditions including emphysema and blindness, and his 32-year-old daughter with depression, anorexia, and substance abuse, died from sodium nit…

psychiatrypsychologysodium nitrite
QLDhospital2024-08-13

Non-inquest findings into the death of RJH

70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide card…

A 70-year-old woman with complex cardiac history including heart failure, paroxysmal atrial fibrillation, and coronary atherosclerosis presented with urinary tract infection and atrial fibrillation on Christmas Day 2021.…

cardiologyemergency medicinediagnosticmedicationflecainide
WAhospital2024-08-09

Inquest into the Death of Lindsay WOODS

48y · Male·metastatic high-grade neuroendocrine carcinoma, treated palliatively

Lindsay Woods, a 48-year-old Aboriginal man with chronic paranoid schizophrenia, organic psychosis, and ischaemic heart disease, died from metastatic high-grade neuroendocrine carcinoma. He was subject to a custody order…

psychiatryoncologyclozapine
WA2024-07-10

Inquest into the Death of Kevin John KEATH

76y · Male·metastatic prostate cancer with terminal palliative care

Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including r…

oncologypalliative caresystemdelay

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