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SAhospital2010-10-25

Coroner's Finding: CAMERON Louise Cherise

32y · Female·ischaemic heart disease complicated by upper gastrointestinal haemorrhage

A 32-year-old woman with schizophrenia presented to the emergency department with chest pain radiating to both arms, profuse sweating, and vomiting black material for several days. She also reported black stools. The fir…

emergency medicinecardiologydiagnosticproceduralmorphine
QLDhospital2010-10-18

Little Gungallida Girl

4y · Female·aspiration of vomitus and its treatment due to rheumatic carditis against a back…

A 4-year-old Aboriginal girl from Doomadgee died on 23 July 2009 from aspiration of vomitus complicating rheumatic carditis with concurrent viral respiratory tract infection. She presented with fever and cough on 19, 21,…

emergency medicinepaediatricsparacetamol
VIChospital2010-09-03

Finding into death of Jacinta Megan Pascoe

0y · Female·Myocardial infarction

Jacinta Pascoe, a 4-week-old premature infant, died of myocardial infarction due to unclear aetiology on 10 July 2007. She presented to Austin Hospital via ambulance on 9 July with vomiting, limpness, and grunting. Clini…

neonatologyemergency medicinecommunicationsystem
NSWhospital2010-09-02

Coxell 2011 06 14 12 32 04 475

61y · Male·cardiac tamponade caused by aortic dissection due to hypertension

Harry Coxell, a 61-year-old man with hypertension, presented to Blacktown Hospital with severe sudden-onset chest pain on 31 October 2006. The Emergency Department doctor, Dr H., assessed him as intermediate risk for isc…

emergency medicinecardiologydiagnosticproceduralglyceryl trinitrate
VIChospital2010-05-31

Finding into death of Paul Alexander Goodwin

85y · Male·Ruptured abdominal aortic aneurysm

An 85-year-old man with known inoperable abdominal aortic aneurysm died from rupture of this aneurysm while hospitalized for acute exacerbation of COPD. A medication error occurred at admission when Dr T. inadvertently i…

general medicinerespiratory medicinemedicationgabapentin
QLDhospital2010-05-07

Cramb, Fay - aka Valmae Beck

64y · Female·Haemorrhage into atheromatous plaque, due to coronary atherosclerosis

Fay Cramb, a 64-year-old woman imprisoned for 20+ years, died on 27 May 2008 from coronary atherosclerosis with haemorrhage into atheromatous plaque. She suffered an acute cardiac event on 5 May 2008 requiring emergency …

cardiologyintensive caresystem
SAcommunity2010-04-01

Coroner's Finding: HALLORAN James Gordon

52y · Male·hypoxic-ischaemic encephalopathy due to cardiac arrest due to unknown aetiology

James Halloran, age 52, collapsed during chiropractic treatment and suffered cardiac arrest of unknown aetiology. He remained unconscious despite resuscitation and died from hypoxic-ischaemic encephalopathy. Initially su…

emergency medicineintensive caredelaycommunication
QLDcommunity2010-03-25

Howlett, Peter David

44y · Male·acute myocardial ischaemia due to coronary artery occlusion due to thrombosis an…

Peter Howlett, a 44-year-old male, died of acute myocardial infarction on 21 April 2006 after a 54-minute delay in ambulance arrival. His wife called Triple 0 reporting back pain radiating to chest at 7:20 am. Critical c…

emergency medicineparamedicinecommunicationdiagnostic
SAhospital2010-02-04

Coroner's Finding: KRIVITCH Olga

81y · Female·hypovolaemic shock following bleeding from the site of a femoral angiogram

Olga Krivitch, 81-year-old woman, died from hypovolaemic shock caused by bleeding from her femoral angiogram puncture site. She was admitted for ischaemic leg and underwent unsuccessful thrombolytic therapy. Subsequently…

vascular surgeryradiologydiagnosticmedicationheparin
QLD2009-12-16

Myers, Robert Hayes

63y · Male·Myocardial infarction as a result of long standing ischaemic heart disease and a…

Robert Myers, a 63-year-old prisoner with long-standing ischaemic heart disease and prior coronary artery bypass grafts, died from myocardial infarction three days after discharge from the Princess Alexandra Hospital. He…

cardiologygeneral practice
QLDmental health2009-12-16

Shishko, Peter

47y · Male·abnormal heart rhythm (arrhythmia) induced by atherosclerosis, occurring in the …

Peter Shishko, a 47-year-old man with bipolar affective disorder, died in a mental health facility while in involuntary detention. He suffered a fatal cardiac arrhythmia on a background of severe coronary atherosclerosis…

psychiatrycardiologydiagnosticsystemdiazepam
SAcommunity2009-12-16

Coroner's Finding: PENN Dulcie Janet Mary

83y · Female·Congestive cardiac failure due to ischaemic and valvular heart disease

An 83-year-old woman with Down syndrome and cardiac disease died from congestive cardiac failure at Royal Adelaide Hospital following accidental medication administration error in a community group home. On 1 July 2007, …

emergency medicineintensive caremedicationproceduralclozapine
QLD2009-11-26

Costelloe, Anthony Gayle

37y · Male·Posterior myocardial infarction consequent upon right coronary artery thrombosis…

Anthony Costelloe, a 37-year-old Aboriginal prisoner, died from myocardial infarction on 25 October 2002, less than 24 hours after presenting to the prison medical centre with chest pain. A registered nurse assessed him …

cardiologyemergency medicinediagnosticcommunication
QLDhospital2009-10-08

Kerkvliet, Kristen

1y · Female·acute myocardial infarction secondary to Kawasaki's Disease

Kristen Kerkvliet, aged 14 months, died from acute myocardial infarction secondary to Kawasaki's Disease. She presented to Gympie Hospital severely underweight and malnourished on 3 February 2006, having failed to thrive…

paediatricsgeneral practicediagnostic
QLD2009-08-21

Oram, Ronald Thomas

49y · Male·Coronary artery occlusion due to, or as a consequence of, coronary artery athero…

Ronald Thomas Oram, a 49-year-old Aboriginal man, died in custody from natural causes—severe coronary artery atheroma with coronary artery occlusion. He presented to the prison nurse on 5 January 2008 with chest pain, wh…

emergency medicinecardiologydiagnosticsystemparacetamol
NThospital2009-06-30

Inquest into the death of Kenneth William Hill

37y · Male·complete blockage of the right anterior descending coronary artery with blood cl…

Kenneth Hill, a 37-year-old Aboriginal man, presented to Royal Darwin Hospital Emergency Department with chest pain and dyspnoea during football training. He was triaged as Category 3 by the triage nurse, who found his p…

emergency medicinecardiologysystem
QLDaged care2009-05-05

Hoy, Raleigh

41y · Male·Dilated cardiomyopathy

Raleigh Hoy, a 41-year-old man with schizophrenia and autistic spectrum disorder, died of dilated cardiomyopathy at a residential care facility (Tarampa After Care Centre) in Queensland in January 2007. While his mother …

psychiatrygeneral practicecommunicationsystemclozapine
SAcommunity2009-03-30

Coroner's Finding: DALLING Brian Terrance and SALOTTI Jack William and GRZYWACZ Richard John and SOBEY Brian Leslie

Male·acute myocardial infarction due to coronary artery disease (all four); specific …

Four rural South Australian men (aged 42-76 years) died from acute coronary syndrome in 2004-2006. All presented to country medical practitioners with symptoms suggestive of acute coronary syndrome but were not identifie…

general practiceemergency medicinediagnosticcommunicationaspirin
QLDhospital2009-03-20

Woolgar, Shealah Ann

83y · Female·Haemorrhage due to mitral valve disease (surgically repaired); specifically haem…

An 83-year-old woman died from haemorrhage following mitral and tricuspid valve repair surgery. During intra-operative testing of the repaired mitral valve using Blake's tubing (soft rubber tubing with a bevelled end) at…

cardiothoracic surgeryanaesthesiaproceduralwarfarin
QLDcommunity2009-02-10

Lee-Chue, Allan Duncan

45y · Male·acute myocardial infarction due to coronary atherosclerosis

Allan Lee-Chue, a 45-year-old man with severe coronary atherosclerosis, suffered a fatal acute myocardial infarction while in police custody during transport to Mareeba police station. He collapsed suddenly in the police…

cardiologyemergency medicine
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