Coronial
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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
VIChospital2012-02-06

Finding into death of David Crisfield

43y · Male·Septic shock from streptococcus pneumoniae sepsis arising from streptococcus pne…

David Crisfield, a 43-year-old immunosuppressed patient with COPD on Crohn's disease therapy, died from streptococcus pneumoniae septic shock. He presented to a rural hospital ED on 6 November 2007 with respiratory compr…

emergency medicinegeneral practicediagnosticcommunicationsalbutamol
NT2012-01-03

Inquest into the death of Steven Andrew Forbes

37y · Male·acute viral pneumonia secondary to swine flu (H1N1) infection of the lungs, exac…

Steven Andrew Forbes, age 37, died of acute viral pneumonia secondary to H1N1 influenza, complicated by chronic rheumatic heart disease. He died in police/correctional custody following arrest at hospital discharge for a…

emergency medicineinfectious diseasescommunicationsystemdicloxacillin
NT2011-11-25

Inquest into the death of Bird

46y · Male·Acute hypoxic brain damage resulting from intentional self-inflicted hanging

A 46-year-old male prisoner died from acute hypoxic brain damage following self-inflicted hanging in custody. He had a history of physical health issues including HIV and mental health concerns including anger management…

psychiatrypsychology
SA2011-11-04

Coroner's Finding: Sleeping Rough Inquest

Multiple: pneumonia with cardiomyopathy (Kugena female); septic shock from pneum…

Concurrent coronial inquests into six Aboriginal deaths in Ceduna, South Australia between 2004-2009. All deceased had severe alcohol addiction and comorbidities including pneumonia, cardiomyopathy, liver disease, and se…

emergency medicinerespiratory medicinesystemdelayalcohol
QLD2011-11-03

Currie, Sheldon Douglas

18y · Male·Hypoglycaemic hypoxic-ischaemic encephalopathy, due to massive liver necrosis, d…

An 18-year-old remand prisoner died from acute liver failure secondary to Hepatitis B and C infection. He presented with fever and malaise on 15 February but was assessed only for boils and not thoroughly evaluated. Clin…

general practicegastroenterologydiagnosticcommunicationflucloxacillin
QLDhospitalPodcast2011-10-07

Saunders, Ryan Charles

2y · Male·Group A Streptococcal toxic shock syndrome which probably originated in the thro…

Ryan Saunders, a 2-year-old boy, died from Group A Streptococcal toxic shock syndrome after a 72-hour presentation with fever, pain, and systemic illness. Initial GP care was appropriate given the presentation and diagno…

paediatricsemergency medicinediagnosticcommunicationparacetamol
QLD2011-09-29

Tiers, Matthew Maurice

53y · Male·Multi-organ failure due to sepsis

Matthew Tiers, a 53-year-old Aboriginal man with extensive comorbidities including alcoholic liver disease, was arrested and detained at Rockhampton Watchhouse then transferred to Capricornia Correctional Centre. He deve…

intensive careemergency medicinediagnosticsystemdiazepam
VIChospital2011-09-19

Finding into death of Stephen Johnson

47y · Male·Multiple organ failure due to Aeromonas Sobria sepsis in a man with cirrhosis

Stephen Johnson, a 47-year-old teacher, died from sepsis caused by Aeromonas Sobria bacteria acquired through a cut hand exposure to contaminated farm water. He presented to hospital with non-specific symptoms and elevat…

emergency medicineinfectious diseasesdelay
SAhospital2011-07-08

Coroner's Finding: BAIS Jamie Stuart

39y · Male·pneumococcal meningitis with severe cerebral oedema due to pneumococcal mastoidi…

Jamie Stuart Bais, a 39-year-old man with acute otitis media and sinusitis, was admitted to Flinders Medical Centre for what was thought to be a straightforward ENT infection. Over 15 days, he developed pneumococcal meni…

ENT surgeryinfectious diseasesdiagnosticcommunicationceftriaxone
NSW2011-07-01

Coroner's Finding: Michael Peter Magro

40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…

Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…

correctional healthgeneral practicediagnosticcommunicationmethadone
NSW2010-12-14

Maryannroberts281 05 finding14december2010

73y · Female·Bacterial endocarditis organism arising from a staphylococcal infection that ent…

Mary Roberts, aged 73, received a 5-year custodial sentence in September 2004. She had complex medical needs: dementia from previous strokes, diabetes requiring insulin monitoring, and Warfarin use. Justice Health provid…

correctional healthgeriatric medicinediagnosticcommunicationwarfarin
SAhospital2010-06-03

Coroner's Finding: PROMNITZ Aileen Dawn

79y · Female·Sepsis due to urinary tract infection with Group B streptococci

A 79-year-old nursing home resident died of sepsis from urinary tract infection with Group B streptococci after waiting 6 hours in the Emergency Department without being seen by a doctor. She arrived at 8pm with normal v…

emergency medicineinfectious diseasesdelaysystem
VIChospital2010-03-24

Finding into death of Adam Michael Francis Fabre

19y · Male·acute bacterial meningitis with secondary cerebritis (meningococcus)

Adam Fabre, a 19-year-old with fever, severe headache, neck pain, muscle pain (10/10), vomiting, tachycardia and blanching rash, presented to Casey Hospital ED at 3:45am on 14 July 2006. Despite expressing clear concern …

emergency medicineinfectious diseasesdiagnosticcommunicationparacetamol/codeine
VIChospital2010-03-15

Finding into death of Deborah Margaret Ricklefs

29y · Female·Invasive aspergillosis

A 29-year-old registered nurse with systemic lupus erythematosus (SLE) died from invasive aspergillosis. Dr G. prescribed lamotrigine 100 mg daily (double the recommended initial dose of 50 mg) on first consultation with…

addiction medicinegeneral practicemedicationdiagnosticlamotrigine
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
QLDhospital2009-12-08

Congoo, Sharon Faye

40y · Female·Bacterial septicaemia from an unknown organism

Sharon Faye Congoo died from overwhelming bacterial septicaemia of unknown origin at age 40. She presented to Mareeba Hospital (a small rural facility) on three occasions with non-specific viral-like symptoms and leg pai…

emergency medicineintensive caresystemcommunication
QLDhospital2009-11-20

Johnston, Margaret Allan

82y · Female·Complications from hypoglycaemic brain damage and cerebral vascular accident

Margaret Allan Johnston, 82-year-old admitted for UTI and confusion, was found comatose on 4 September 2006 with severe hypoglycaemia (glucose 0.8 mmol/L) despite being non-diabetic. Blood tests revealed high insulin and…

anaesthesiaendocrinologymedicationsysteminsulin
SAhospital2009-09-11

Coroner's Finding: LANGFORD Peter

64y · Male·hospital-acquired pneumonia on a background of end-stage cryptogenic liver cirrh…

Peter Langford, aged 64, died of hospital-acquired pneumonia complicated by end-stage cryptogenic liver cirrhosis after a 43-day admission to Flinders Medical Centre. He presented with severe cellulitis requiring amputat…

gastroenterologygeneral medicinesystemlactulose
SAhospital2009-05-22

Coroner's Finding: ROBERTS Jarrad Delroy

10y · Male·sepsis (fusobacterium necrophorum) complicating right otitis media

Jarrad Roberts, a 10-year-old with learning disabilities and likely ADHD, died from sepsis due to untreated right otitis media caused by Fusobacterium necrophorum. He had been acutely ill for 5-7 days before finally seei…

paediatricsgeneral practicedelaysystemamoxicillin

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