Coronial
TAShospital2018-01-24

Coroner's Finding: Woolley, Paul James

50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngea…

… Critical failures in post-operative management at a private hospital included: failure to ensure continued CPAP use despite surgeon and anaesthetist expectations, and absence of continuous oxygen saturation monitoring. …

ENT surgeryanaesthesiacommunicationsystemmorphine
VICaged care2022-02-15

Finding into death of Melissa Cunningham

44y · Female·Complications of a lung abscess with contributing factors of Down's syndrome and…

…ld woman with Down's syndrome and severe obesity, died from complications of a lung abscess. She required a CPAP machine for sleep apnoea, prescribed and monitored by Western Health since 2013. Western Health provided ex…

respiratory medicinegeriatric medicinesystemcommunication
VICmental health2023-11-03

Finding into death of Abdurahman Faid

48y · Male·unascertained

…ndrome diagnosed shortly before admission. During his psychiatric admission, he remained non-compliant with CPAP therapy due to agitation and psychosis. His oxygen saturations were monitored regularly and remained border…

psychiatryrespiratory medicineolanzapine
VIChospital2022-08-31

Finding into death of Cindy Jane Martin

40y · Female·Complications of WHO Class III Obesity

…ng effects in the presence of untreated sleep apnoea created physiological risk. She had previously refused CPAP use despite availability. The coroner found care reasonable but identified a systems gap: no clear protocol…

psychiatryrespiratory medicinesystemdelaysodium valproate
WAhospital2023-11-29

Inquest into the Death of Samuel Edward ASHBY

46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…

…d obstructive sleep apnoea; (4) support for patients with cognitive impairment to maintain medical devices (CPAP) is essential. Clinicians should monitor clozapine levels closely when patients change smoking habits, adhe…

psychiatrygeneral medicinediagnosticsystemclozapine
NSWcustody2022-07-21

Inquest into the death of Richard Navarro

43y · Male·Hypoxic Ischaemic Encephalopathy due to out of hospital cardiac arrest, secondar…

…g sleep approximately one hour after lights-out on his first night in custody, without access to his custom CPAP machine (which his family was bringing the next morning). The coroner found no evidence of negligence by Co…

respiratory medicinecardiologysystem
NSW2022-12-06

Inquest into the death of Jason RADFORD

48y · Male·Fatal cardiac arrhythmia which was the result of obstructive sleep apnoea

…onditions. The coroner found his medical care was appropriate: his sleep apnoea was adequately managed with CPAP, cardiac monitoring with regular ECGs was performed, and his QT interval prolongation risk from methadone w…

cardiologygeneral practicemethadone
SA2022-03-30

Coroner's Finding: Hohol, Peter

68y · Male·decompensated heart failure with pulmonary hypertensive crisis complicated by pn…

… days before emergency transfer to hospital. Key clinical issues identified were: (1) unavailability of his CPAP machine despite documented obstructive sleep apnoea requiring it in the community; (2) mobility barriers li…

cardiologygeneral medicine
NSW2023-11-16

Inquest into the death of DP

52y · Male·hanging

… ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He had requested a CPAP machine for over 9 months without receiving one, which he believed exacerbated his depression. The coroner …

psychiatrygeneral practicediagnosticsystemduloxetine
SAhospital2018-04-26

Coroner's Finding: JEISMAN Leonie Faye

45y · Female·Type 2 respiratory failure and aspiration pneumonia on a background of end-stage…

…or five months until her death. Her condition progressively worsened despite treatment, complicated by poor CPAP compliance, ongoing smoking, and inability to be discharged to alternative care settings. Palliative care w…

respiratory medicinegeneral medicine
NThospital2025-03-25

Inquest into the death of Judith Smart

66y · Female·Hypoxic-ischaemic encephalopathy

…nuous close observation post-operatively; oxygen saturation modifications require thorough clinical review; CPAP machines must be immediately available; high-risk patients need specialized monitoring units, not general w…

anaesthesiaorthopaedic surgerydiagnosticsystemmorphine
SAmental health2008-07-17

Coroner's Finding: TARNOWSKI Marek Tomasz

33y · Male·Respiratory failure due to mixed drug toxicity (amitriptyline, oxycodone, morphi…

…gabapentin) for pain and depression management. Found unresponsive while sleeping on a mattress without his CPAP machine, he had vomited prior to collapse. The coroner found no single preventable factor, noting that insi…

psychiatryemergency medicinesystemamitriptyline
WAhome2021-06-22

Inquest into the Death of Child AM (Name Subject to Suppression Order)

3y · Female·bronchopneumonia in an infant with obstructive sleep apnoea

…ary complications including right heart hypertrophy, pulmonary hypertension, and sleep apnoea. She required CPAP/BiPAP support which compliance was poor. The coroner found the child had been appropriately investigated an…

paediatricsrespiratory medicinecommunicationsystem
QLDmental health2009-12-16

Shishko, Peter

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

…ea and cardiac risk; two concurrent antipsychotic medications were suboptimal; and a previously recommended CPAP device was not provided. Better coordination of cardiac and psychiatric care, closer monitoring of vital si…

psychiatrycardiologydiagnosticsystemdiazepam
SA2026-03-13

Coroner's Finding: Holding, Matthew Benjamin

44y · Male·unascertained

…ration (90-91%), and facial swelling from a dental issue. Medical staff recommended hospital assessment and CPAP therapy for suspected sleep apnoea; he refused both despite being informed of death risk. He fell in his ce…

psychiatrycorrectional healtholanzapine
VIChospital2025-10-13

Finding into death of David Greville Edward Horne

47y · Male·Unascertained; most likely cardiac arrhythmia possibly triggered by obstructive …

David Horne, a 47-year-old man with bipolar disorder, schizoaffective disorder, and severe obstructive sleep apnoea, died suddenly at Maroondah Hospital while under compulsory psychiatric treatment. He experienced two ep…

psychiatryrespiratory medicinediazepam
WAprison2021-09-06

Inquest into the Death of Marshall Ruben EDGILL

38y · Male·combined effects of acute-on-chronic respiratory disease and cardiomegaly

…htness, missing heartbeat). While OSA was not directly diagnosed via sleep study, expert evidence indicates CPAP therapy may have prevented death by reducing cardiac failure risk. The coroner found the Department failed …

respiratory medicinecardiologydiagnosticdelay
NSWhospital2023-08-22

Inquest into the death of AN

0y · Female·Methylamphetamine toxicity

…rations. Initial clinical management was appropriate—the baby showed mild respiratory distress managed with CPAP, had normal vital signs, and was transferred to special care nursery for monitoring. The acute deterioratio…

neonatologypaediatricsmethamphetamine
QLD2025-06-26

Non-inquest findings into the death of Peter Raymond Thistleton

61y · Male·Multiple injuries due to motor vehicle collision (driver)

… to disable sensors. Contributing factors included undiagnosed sleep apnea with interrupted sleep (refusing CPAP therapy), cannabis use detected in blood, evidence of habitual speeding, and poor logbook compliance. The c…

cannabis
NSWhospital2014-09-26

Inquest into the death of AA

10y · Male·Hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…

…terventions and explicit warnings that his condition was life-threatening, parents failed to use prescribed CPAP equipment, attend follow-up appointments, or implement dietary changes. Key systemic failures included: lac…

respiratory medicineendocrinologycommunicationsystemmethadone

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