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QLDhome2013-05-31

Garrett-Pratt, Jake Michael

12y · Male·Head injuries resulting from ride-on mower collision

Jake Garrett-Pratt, a 12-year-old boy, died from fatal head injuries sustained when he lost control of a poorly maintained ride-on lawn mower on a steep driveway. The rear axle drive chain broke due to inadequate mainten…

emergency medicinetrauma surgerysystemdelay
QLDhospital2013-05-22

Thoresen, Cynthia

88y · Female·pulmonary thromboembolism due to fractured right femur due to a fall

Cynthia Thoresen, 88-year-old woman with dementia and osteoporosis, fell at home and sustained a fractured femur approximately three weeks before admission. Her daughter, the registered carer, failed to seek medical atte…

orthopaedic surgeryemergency medicinedelaysystemmorphine
WAhospital2013-02-11

Inquest into the Death of Carroll

21y · Male·Acute hypoxic ischaemic encephalopathy and pneumonia in a man with recent trauma…

Peter Martin Carroll, age 21, died on 8 June 2007 in the ICU at Royal Perth Hospital from acute hypoxic ischaemic encephalopathy and pneumonia following oxycodone overdose. He had been discharged that day (5 June) after …

emergency medicineorthopaedic surgerycommunicationsystemoxycodone
VICaged care2013

Finding into death of Moira McCarthy

85y · Female·Hypostatic bronchopneumonia complicating fractured occipital condyle and left ne…

Moira McCarthy, an 85-year-old woman with dementia and multiple comorbidities requiring high-level aged care nursing, sustained a fall on 24 April 2013 when a ceiling hoist descended unexpectedly during a patient transfe…

geriatric medicineorthopaedic surgeryproceduralcommunicationmorphine
QLDhospital2012-11-28

Hammett, Christopher

47y · Male·Aspiration pneumonia due to or as a consequence of coronary atherosclerosis

Christopher Hammett, a fit 47-year-old, died from aspiration pneumonia with contributing coronary atherosclerosis following routine L5-S1 disc replacement. A critical oxygen desaturation (64%) occurred during transfer fr…

orthopaedic surgeryanaesthesiadiagnosticcommunicationmorphine
NSWhospital2012-11-20

Channell & ivanoska decision

Female·Pulmonary thromboembolism due to deep vein thrombosis following lower leg fractu…

Two women aged 48 and 59 presented to Shellharbour Hospital ED with lower leg fractures sustained in falls. Both were treated conservatively with immobilization (splint and plaster back slab) and discharged home without …

emergency medicineorthopaedic surgerydiagnosticsystem
QLDaged care2012-10-19

Anderson, Stanley Charles

86y · Male·coronary and cerebral atherosclerosis with significant conditions of fractured l…

Mr. Stanley Charles Anderson, aged 86, died at Gympie General Hospital from coronary and cerebral atherosclerosis, precipitated by injuries sustained in a fall at a nursing home. While transferring from a bath trolley to…

geriatric medicineoccupational and environmental healthsystemcommunication
SAhospital2012-06-25

Coroner's Finding: POLKLASER Irmgard Giesela

76y · Female·Aspiration pneumonia complicating surgery for pelvic and spinal fractures on a b…

A 76-year-old woman died from aspiration pneumonia following surgery for pelvic and spinal fractures sustained in a fall on a shopping centre travelator. She fell when her husband lost control of a shopping trolley with …

orthopaedic surgerytrauma surgerysystemdelay
QLDhospital2012-06-22

Paton, Daniel William

45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia

A 45-year-old man died from hypoxic-ischaemic encephalopathy following cardiopulmonary arrest 11 hours after elective wrist plate removal surgery. Multiple contributing factors were identified: undisclosed obstructive sl…

anaesthesiapain medicinediagnosticmedicationmorphine
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
QLDhospital2011-11-04

Smith, Darryl Robert

34y · Male·Air embolism and severe haemorrhage due to perforation of the right subclavian v…

Darryl Smith, aged 34, died following emergency surgery for a fractured clavicle at Sunnybank Private Hospital. During the final drilling of the sixth screw hole, the surgeon's drill penetrated the underlying right subcl…

orthopaedic surgeryanaesthesiaproceduraldelayadrenaline
SAhospital2011-08-05

Coroner's Finding: SEMMLER Howard Malcolm

60y · Male·cardiorespiratory failure due to malignant pleural effusion due to metastatic ma…

A 60-year-old man with diabetes presented with a plantar heel ulcer in March 2007 that was initially treated as a diabetic foot ulcer. The lesion failed to heal over 16 months despite standard care including wound dressi…

general practiceorthopaedic surgerydiagnosticdelay
VICaged care2011-07-18

Finding into death of Annie Kane

93y · Female·Complications of fractured neck of femur in a woman with congenital heart failur…

Annie Kane, 93, with congestive heart failure and hypertension, sustained a fractured neck of femur following an unwitnessed fall at Jasmine Lodge supported residential service in July 2009. The fall occurred in an area …

geriatric medicinegeneral medicinesystem
SAhospital2011-04-07

Coroner's Finding: WATKINS Maureen

56y · Female·pulmonary thromboembolism due to left calf deep vein thrombosis

A 56-year-old woman with bipolar disorder died from pulmonary thromboembolism due to left calf deep vein thrombosis while detained under the Mental Health Act in hospital. She presented with seizures and underwent wrist …

general medicinepsychiatrydiagnosticcommunicationdiazepam
QLDhospital2010-10-29

Spence, Samantha Rose

12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…

Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI of her spine. A paediatric…

orthopaedic surgeryneurologydiagnosticcommunicationmorphine
VICcommunity2010-10-19

Finding into death of Patrick Tolan

55y · Male·Multiple injuries sustained in a fall

Patrick Tolan, a 55-year-old man with chronic depression, alcohol dependence, and multiple suicide attempts, died from injuries sustained in a fall from a shopping centre sign. He had jumped from a parapet four years ear…

psychiatryorthopaedic surgerydiagnosticcommunicationmirtazapine
NThome2010-01-19

Inquest into the death of Deborah Leanne Melville

12y · Female·acute septicaemia resulting from osteomyelitis of the left femur

A 12-year-old Aboriginal girl died from septicaemia caused by untreated osteomyelitis of the left femur. Three weeks after a sports injury, despite evidence of severe and deteriorating illness including inability to walk…

orthopaedic surgeryinfectious diseasesdiagnosticsystem
NThospital2009-11-27

Inquest into the death of Alma June Green

82y · Female·acute peritonitis, ruptured bowel and incarcerated bowel herniation

An 82-year-old woman admitted with bowel obstruction recovered well initially but suffered a preventable fall in the radiology department when left unattended with heavy IV pumps on her wheelchair, fracturing her hip. Af…

general surgeryradiologydiagnosticcommunicationoxycodone
NThospital2008-12-18

Inquest into the death of Paulo Melo

29y · Male·Blunt head and neck injuries sustained in an unintentional motor vehicle acciden…

A 29-year-old man sustained severe blunt head and cervical spinal cord injuries in a motor vehicle accident. He remained unconscious with high intracranial pressure and C5 spinal cord transection. After 12 days with no i…

intensive caretrauma surgerycommunicationmorphine
NThospital2008-10-29

Inquest into the death of Sandra McRae

57y · Female·acute pulmonary embolism

Sandra McRae, age 57, died from pulmonary embolism on day 13 of hospitalisation following pelvic fractures sustained in a motor vehicle accident. The coroner found the death was potentially preventable due to failure to …

orthopaedic surgeryintensive carediagnosticsystem
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