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VIChospital2015-10-14

Finding into death of Marc Phillip Vella

39y · Male·Infective endocarditis, with intravenous drug use as a contributing factor

Marc Vella, a 39-year-old man with schizophrenia and intravenous drug use, presented to St Vincent's Hospital with respiratory symptoms and chest pain. Clinical assessment identified pneumonia, septicaemia, and possible …

emergency medicinegeneral medicinemethamphetamine
QLDhome2015-10-14

Thomas, Alexander David Joseph - Non-inquest findings

23y · Male·Beta-phenylethylamine toxicity

A 23-year-old Army private died from beta-phenylethylamine toxicity after ingesting excessive quantities of this supplement purchased online. He had a history of low mood, fatigue, and anxiety, and had self-medicated wit…

psychiatryinfectious diseasessystembeta-phenylethylamine
NSWhospital2015-08-17

Inquest into the death of Manjit SINGH

33y · Male·hypoxic respiratory failure following right pneumonectomy for treatment of sever…

Manjit Singh, a 33-year-old Indian 457 visa worker, died from hypoxic respiratory failure following a pneumonectomy for treatment of severe pulmonary tuberculosis. He had latent TB identified pre-arrival in India. Critic…

respiratory medicinecardiothoracic surgerydiagnosticcommunicationtuberculosis medications
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
VICcommunity2015-04-05

Finding into death of James Michael Hoctor

93y · Male·Complications following colectomy for Clostridium difficile pancolitis in the se…

A 93-year-old man with a history of antibiotic use for a neck abscess developed diarrhoea during hospitalisation. Despite testing negative for Clostridium difficile at St Vincent's Hospital, he was transferred to a rural…

general practiceinfectious diseasesdiagnosticpenicillin
WAhospital2014-12-30

Inquest into the Death of Gheorghe Gruici

71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…

Gheorghe Gruici, a 71-year-old life-sentenced prisoner, died of organ failure from chronic renal failure, infective endocarditis, and chest infection. Over 15 years in custody, he developed multiple comorbidities includi…

general medicinenephrologyomeprazole
VIChospital2014-12-16

Finding into death of Michael Justin Nicoll

36y · Male·Multiorgan failure complicating Streptococcus pyogenes septicaemia

Michael Nicoll, 36, presented to Cabrini Hospital ED with diarrhoea, vomiting, and dehydration. Dr P. diagnosed gastroenteritis and discharged him after IV fluids, despite dehydration, tachycardia, elevated creatinine, a…

emergency medicineintensive carediagnosticsystemondansetron
QLDhospital2014-12-08

Gulliver, Graeme Barry; Harrison, Joanne Lee; Morten, Aileen Margaret

21y · Male·Sepsis caused by Leptospirosis (Graeme Gulliver); Group A streptococcal meningit…

Three young patients died from severe bacterial infections at rural Queensland hospitals (Mossman and Atherton). All three received delayed diagnoses and treatment. The first patient (21-year-old with leptospirosis) pres…

emergency medicineinfectious diseasesdiagnosticsystem
VIChospital2014-12-04

Finding into death of Leroy William Scott

1y · Male·Staphylococcus aureus septicaemia of unknown origin

Leroy William Scott, a 15-month-old boy, presented to Geelong Hospital with fever, lethargy, and poor oral intake. He was triaged as semi-urgent and not seen by a doctor until 5 AM, 8 hours later. Blood cultures drawn at…

paediatricsemergency medicinediagnosticcommunicationparacetamol
VIChospital2014-11-26

Finding into death of Ming Shan Yuan

88y · Male·Tuberculous pneumonia in the setting of multiple rib fractures, osteoporosis and…

Ming Shan Yuan, an 88-year-old man with osteoporosis and cachexia, died from tuberculosis pneumonia precipitated by multiple rib fractures. He suffered elder abuse and neglect by his primary carer daughter over months be…

emergency medicinegeriatric medicinediagnosticdelayantibiotics
TAShospital2014-09-19

Coroner's Finding: Tetley, Barry Lindsay

72y · Male·sepsis of undetermined source (pneumonia or spinal epidural abscess)

A 72-year-old man presented to ED with back pain, fever, elevated inflammatory markers (CRP 77.9, high WBC), hypotension (98/59 mmHg at 6:30am), hyponatremia, and hypoalbuminemia—all consistent with sepsis. Despite these…

emergency medicineintensive carediagnosticcommunication
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
NTcommunity2014-09-01

Inquest into the death of Braydon Brown

17y · Male·bacterial meningitis

A 17-year-old Aboriginal student died from bacterial meningitis after three clinic presentations in Yuendumu over four days. The critical failure occurred on 1 April when fever (38.3°C), persistent headache, and positive…

general practiceemergency medicinediagnosticcommunicationdiazepam
NSWhospital2014-05-09

Inquest into the death of Tama GALIERE

0y · Unknown·focal ventricular myocarditis and myonecrosis resulting from migration of a Peri…

A 10-month-old boy died from myocarditis and myonecrosis caused by migration of a PICC line into his right ventricle. The line was inserted appropriately under general anaesthetic for IV antibiotics treating periorbital …

paediatricsanaesthesiaproceduralcommunication
VIChospital2014-05-05

Finding into death of Georg Manfred Braumuller

41y · Male·pneumonia in the setting of Lennox Gastaut Syndrome

A 41-year-old man with Lennox Gastaut Syndrome and significant physical disabilities died from pneumonia two days after presenting to his GP with fever and cough. The GP diagnosed a respiratory tract infection and prescr…

general practicerespiratory medicinesystemantibiotic medication
WAhospital- 8 July 2014

Inquest into the Death of Delray BEASLEY

56y · Male·unascertainable; complications of liver cirrhosis and/or exposure most likely

Delray Beasley, a 56-year-old Aboriginal man with chronic liver cirrhosis from longstanding alcohol abuse, was admitted to Kalgoorlie Hospital in May 2010 following an alleged assault. He was initially evaluated for poss…

emergency medicineneurosurgerysystemdiazepam
WAprison- 31 January 2014

Inquest into the Death of Amy TINKER

33y · Female·multiple organ failure complicating sepsis in a woman with cirrhosis of the live…

Amy Tinker, a 33-year-old Aboriginal woman with unrecognised cirrhosis from chronic alcohol abuse, died from sepsis-related multi-organ failure while imprisoned. She had been admitted to Royal Perth Hospital in 2004 with…

general practicehepatologycommunicationsystem
WAhospital2013-11-28

Inquest into the Death of Scafidas, Allegra Amelie

0y · Female·Pneumococcal meningitis

Allegra, aged 6 months, died of pneumococcal meningitis after a Healthdirect telephone triage call on 28 April 2010 that resulted in inappropriate home-care advice. She presented with fever (38.9°C), shallow rapid breath…

paediatricsinfectious diseasesdiagnosticsystemparacetamol
NT2013-11-20

Inquest into the death of Sara Lorraine Hampel

21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…

Sara Hampel, 21 years old, died from sepsis caused by necrotising fasciitis (Group A Streptococcus) on 14 October 2011, presenting 8 days post-partum with severe leg pain and multiple signs of sepsis. Critical failures i…

obstetricsemergency medicinediagnosticcommunicationparacetamol
TAS2013-11-06

Coroner's Finding: Sullivan, Craig

18y · Male·rupture of a left frontal cerebral abscess

An 18-year-old male detainee at Ashley Youth Detention Centre died from rupture of a left frontal cerebral abscess likely caused by sinus infection. Craig was admitted on remand in early October 2010 and presented with i…

infectious diseasesneurosurgerysystemdelay
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