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NSWaged care2019-09-27

Inquest into the death of Epenesa PAHIVA

87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…

Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (h…

dermatologygeneral practicediagnosticcommunicationbleach
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
ACThome2019-06-04

Inquest into the death of Lauren Maree Johnstone

48y · Female·Combined toxic effect of prescription and non-prescription medications including…

Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…

general practicesurgerycommunicationsystemdoxylamine
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
VIChospital2018-08-31

Finding into death of David William Lobb

53y · Male·Complications of burns sustained in a blast

A 53-year-old qualified boiler maker died from complications of severe burns sustained in a gas explosion. While attempting to remove a refrigeration compressor from a hotel cellar with an unqualified colleague, they cut…

intensive caretrauma surgeryproceduralsystem
NSWhome2018-07-06

Inquest into the death of Miata Jibba

9y · Female·complications of thermal injury

A 9-year-old child died from severe thermal injuries sustained in a house fire. The property had non-functional smoke alarms that the property management company knew about but failed to remedy or report to the landlord.…

intensive careplastic and reconstructive surgerycommunicationsystem
VIChome2017-12-04

Finding into death of Leigh Thomas Aiple

31y · Male·Pulmonary thromboembolism

A 31-year-old man with obesity (BMI 40.2) and sleep apnoea underwent extensive cosmetic surgery in Malaysia (liposuction, abdominoplasty, chest lipectomy, and subsequent facial procedures) across two operations within fi…

plastic and reconstructive surgerygeneral surgerydiagnosticmedicationenoxaparin
WAcommunity2017-06-12

Inquest into the Death of Wendy BEARFOOT

45y · Female·multiple organ failure following thermal injuries (severe burns)

Wendy Bearfoot, a 45-year-old DEC (Department of Environment and Conservation) employee, died from multiple organ failure following severe thermal burns (80% of body) sustained in a bushfire burnover on 12 October 2012. …

emergency medicineplastic and reconstructive surgerycommunicationdiagnostic
NSW2016-07-15

Inquest into the death of Sheila Drysdale

75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …

A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…

plastic and reconstructive surgerygeriatric medicinemedicationproceduralaspirin
QLDaged care2016-06-15

Drane, John Edward

75y · Male·Burns

75-year-old John Drane, a resident of Masonic Care Queensland, died from extensive burns on 9 January 2014. The coroner concluded he intentionally set himself alight using a cigarette lighter shortly after receiving his …

oncologygeriatric medicinediagnosticcommunicationchemotherapy agents
VIChospital2015-03-03

Finding into death of Matthew Jack Whyte

3y · Male·Brainstem ischaemia in association with Arnold Chiari malformation

Matthew Whyte, a 3-year-old with Arnold Chiari malformation and hydrocephalus, died from brainstem ischaemia following multiple shunt complications and emergency decompression surgery. The coroner found that after Matthe…

neurosurgeryplastic and reconstructive surgerydiagnosticcommunication
VIChospital2014-09-11

Finding into death of Daniel Raymond Cowan

15y · Male·global hypoxic cerebral injury following medical intervention for high velocity …

Daniel Cowan, aged 15, sustained a penetrating head injury from a homemade air gun while with friends. Despite appropriate emergency response and comprehensive multidisciplinary medical management at Royal Children's Hos…

neurosurgeryintensive caremidazolam
SAcommunity2012-11-15

Coroner's Finding: Edgar Lauren Michelle

28y · Female·Multi-organ failure due to Clostridium perfringens myonecrosis complicating lipo…

Lauren Edgar, a 28-year-old woman, died of multi-organ failure from Clostridium perfringens myonecrosis (gas gangrene) following a liposuction procedure performed by Dr K. on 5 March 2008. She presented to hospital on 8 …

plastic and reconstructive surgerygeneral practicediagnosticcommunicationpanadol/paracetamol
VIChospital2012-09-11

Finding into death of Robert Anderson

50y · Male·Complications of right buttock necrotising fasciitis secondary to chronic right …

50-year-old male with chronic pain from jockey injuries became dependent on morphine. General practitioner prescribed intramuscular (IM) morphine for self-administration at home from 2005–2007 at doses of 120–240mg daily…

general practicepsychiatrydiagnosticmedicationmorphine sulphate
WAhospital2012-05-31

Inquest into the Death of GARRETT

52y · Male·HIV infection complicated by basal and squamous cell carcinoma of the head and n…

Bruce Jason Garrett, a 52-year-old prisoner detained under the Dangerous Sexual Offenders Act, died at Royal Perth Hospital on 2 October 2010 from HIV infection complicated by basal and squamous cell carcinoma of the hea…

emergency medicineintensive careheparin
SAhospital2012-04-13

Coroner's Finding: PROCTOR Janis Mary

56y · Female·multi-organ failure complicating severe burns on a background of alcoholic liver…

A 56-year-old woman with alcoholic liver disease, cerebellar atrophy, and marked mobility impairment suffered fatal full-thickness burns (75% TBSA) from scalding shower water at Flinders Medical Centre. She was left unat…

plastic and reconstructive surgeryphysiotherapycommunicationsystem
VIChospital2012-04-05

Finding into death of Abdullah Kocoglu

4y · Male·Complications of cutaneous thermal burn injuries

Abdullah Kocoglu, age 4, died from complications of severe thermal burn injuries sustained in a house fire on 14 February 2011 at his grandparents' home in Hampton Park, Victoria. The fire was ignited when Abdullah playe…

plastic and reconstructive surgeryintensive caresystemdelay
VIChospital2012-02-22

Finding into death of Ellen Mary OConnor

90y · Female·Renal failure secondary to gentamicin therapy for urinary tract infection (sepsi…

Ellen O'Connor, a 90-year-old woman with renal artery stenosis and coronary artery disease, died from acute renal failure following gentamicin administration for Pseudomonas aeruginosa urinary tract infection. A single 2…

orthopaedic surgeryplastic and reconstructive surgerymedicationdiagnosticgentamicin
QLDhospital2011-06-24

(C) a 15 month old child

1y · Male·Complication of burns and trauma to the mesenteric artery

A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unk…

paediatricsplastic and reconstructive surgerycommunicationsystemrisperidone
VICcommunity2010-08-06

Finding into death of Lauren Katherine James

26y · Female·Complications of liposuction surgery: sepsis, decreased respiratory function sec…

Lauren James, a 26-year-old woman, died from complications of elective liposuction surgery performed on 19 January 2007. She presented to the clinic on 22 January with severe pain and asymmetrical swelling of her left th…

plastic and reconstructive surgerygeneral practicediagnosticcommunicationpethidine

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