Coronial
VIChospital2015-12-02

Finding into death of Khodr El Mustapha

77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…

…renaline administration, limiting detection of cardiac complications. Earlier investigation and oral iron therapy may have prevented the need for IV iron altogether.

emergency medicinehaematologydiagnosticproceduraliron polymaltose
SAhospital2016-05-05

Coroner's Finding: FALKENBERG Malcolm David

77y · Male·septic shock due to cellulitis of the left forearm

Malcolm Falkenberg, a 77-year-old man with dementia, died from septic shock due to cellulitis of the left forearm. He had been living independently with declining self-care and hygiene. Following a guardianship order, he…

geriatric medicineemergency medicinediagnosticdelayantibiotics
WAhome2020-07-01

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

2y · Female·Complications relating to metastatic neuroblastoma

…tage IV high-risk neuroblastoma (N-myc positive) received intensive, world-class treatment including chemotherapy, surgery, mega-therapy, radiotherapy, and biotherapy at Princess Margaret Hospital. She initially achieve…

oncologypaediatric surgerychemotherapy agents
NSW2021-10-12

Inquest into the death of Donald GREENAWAY

88y · Male·Metastatic prostate carcinoma

…ional Centre. He had been diagnosed with stage IV prostate cancer in 2009 and received external beam radiotherapy. During his 6+ years in custody, his cancer re-emerged around 2017 with bony metastases detected on imagi…

oncologyradiation oncologyandrogen deprivation therapy
WAhospital2009-09-11

Inquest into the Death of Gordon

1y · Female·pneumonia (staphylococcal pneumonia with bilateral bacterial pneumonia)

Jezelle Lisa Gordon, a 1-year-old child, died of staphylococcal pneumonia on 26 February 2006 in Port Hedland, Western Australia. She presented to Halls Creek Hospital on 25 February with fever, elevated respiratory rate…

general practiceemergency medicinediagnosticdelayparacetamol
TASaged care2017-05-08

Coroner's Finding: Handasyde, Robert Neil

86y · Male·Sepsis with septic shock, due to urinary tract infection, pyelonephritis (kidney…

…lure to diagnose bladder obstruction despite clear clinical indicators, inappropriate oral antibiotic monotherapy for septic shock (requiring IV antibiotics and hospital admission), and excessive opioid dosing causing t…

general practicecardiologydiagnosticmedicationclopidogrel
VIChospital2016-12-15

Finding into death of Henry Francis Oakley

85y · Male·pneumonia

… He developed a lower respiratory tract infection in December 2015 that persisted despite oral antibiotic therapy. On 28 January 2016, he was found with altered mental status, tachypnoea, and reduced Glasgow Coma Scale …

emergency medicineinfectious diseasesamitriptyline
NSWhospital2015-07-27

Inquest into the death of Lynette Maree YOUNG

46y · Female·Shock following interferon alpha treatment following removal of a melanoma

…Category 2 patient; failure to document observations and maintain fluid balance charts in a patient on IV therapy; inadequate handover between shifts; absence of the primary nurse from HDU without proper handover of car…

oncologycardiologydiagnosticcommunicationinterferon alpha
VIChome2022-09-27

Finding into death of Colleen Mary Chapman

59y · Female·Myocardial infarction secondary to ischaemic heart disease

…ctor. She had been treated for a recent myocardial infarction in December 2019 and was on anticoagulation therapy. The Disability Services Commissioner identified that Ms Chapman lacked a weight management plan despite …

cardiologyemergency medicinesystemcommunicationcarbamazepine
VIChospitalNew2026-07-01

Finding into death of HJW

69y · Female·Urosepsis secondary to anuric acute renal failure and corona radiata infarct; co…

A 69-year-old diabetic woman presented to Maroondah Hospital Emergency Department on 9 June 2024 with severe right-sided abdominal pain and vomiting. CT imaging at 10:00am confirmed emphysematous pyelitis (gas-forming ki…

emergency medicinegeneral medicinediagnosticdelayfentanyl
QLD2026-05-26

Inquest into the death of Desmond George Buckby

74y · Male·Left cerebral ischaemic stroke caused by cerebral arterial cardioembolism

…ves. He was rapidly transported to Princess Alexandra Hospital where he received appropriate thrombolytic therapy but made no meaningful recovery. After consultation with the Public Guardian, he was transitioned to pall…

emergency medicineneurologyalteplase
WAhome2012-06-29

Inquest into the Death of Operation Lantana

Toxicity from intravenous caesium, DMSO, and other substances administered as pa…

In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr B.'s home in Perth, Western Australia, administering intravenous treatment containing caes…

general practiceoncologydiagnosticproceduralcaesium chloride
NSWhospital2018-08-24

Inquest into the death of Phillip Ibrahim

39y · Male·Hypoxic/Ischaemic Encephalopathy due to Cerebral Arterial Gas Embolism

Phillip Ibrahim, a 39-year-old man recovering well from community-acquired pneumonia in ICU, suffered a fatal cerebral air embolism on 28 October 2014. A CVAD removal order was given at midday but the device remained in …

intensive careemergency medicinecommunicationprocedural
SAcommunity2008-12-18

Coroner's Finding: EDWARDS Adrian Lee

31y · Male·haemorrhage due to incised wound to left arm with amphetamine toxicity as a poss…

…th a deep laceration to his left arm (cephalic vein injury). He was extremely combative, resisting oxygen therapy and IV access. Handcuffs were applied to the stretcher to enable safe transport and medical treatment. Du…

emergency medicineforensic medicinedextroamphetamine
TAShospital2024-11-04

Coroner's Finding: de-identified EK

80y · Male·haemorrhagic stroke caused by Staphylococcus aureus sepsis due to L4/5 discectom…

An 80-year-old man underwent elective microdiscectomy for spinal pain in April 2023. In late June, he developed a wound infection with Staphylococcus aureus causing discitis. Despite appropriate diagnosis and aggressive …

orthopaedic surgeryinfectious diseasesantibiotics
VIChospital2010-03-05

Finding into death of Jock Allan Adams

68y · Male·Pneumonia due to bowel obstruction due to follicular lymphoma

…ison with a history of diabetes, schizophrenia, early dementia and follicular lymphoma (treated with chemotherapy), was admitted to St Vincent's Hospital on 7 December 2007 with small bowel obstruction. He underwent lap…

general surgeryoncology
WA2013

Inquest into the Death of Banh, Bac Lam

54y · Male·Early bronchopneumonia complicating subarachnoid haemorrhage due to a ruptured b…

Bac Lam Banh, a 54-year-old prisoner at Walpole Work Camp, suffered a ruptured berry aneurysm while working on 4 September 2012. He received prompt first aid from prison staff and emergency responders, with transfer to A…

neurosurgeryemergency medicinediagnosticphenytoin
VIChospital2014-05-20

Finding into death of Rae Lynn Lukies

57y · Female·Aspiration pneumonia in a woman with cerebral palsy

…d respiratory distress, prompting emergency admission. Hospital management included IV antibiotics, fluid therapy, and a MET call for hypoxia. Following discussion with family about her poor baseline functioning and fut…

general practiceemergency medicinedelaycefalexin
WAhospital2024-08-28

Inquest into the Death of Matthew John PICKIN

56y · Male·Complications, including sepsis, of left leg infection (operated), in a man with…

…gated following haemoptysis in October 2021, with timely referral to specialists and commencement of radiotherapy, chemotherapy, and immunotherapy in January 2022. Medical care was comparable to community standards and …

respiratory medicineoncologysystemdexamethasone
VIChospital2014-09-12

Finding into death of Nola Margaret Moxon

77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression

77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission, no medical review occurred over the weekend prior to …

psychiatrygeriatric medicinecommunicationsystemvenlafaxine

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