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SAhospital2026-04-23

Coroner's Finding: Wilson, Charles Thomas

85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …

An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …

cardiologygeriatric medicinemedicationcommunicationmetoprolol
SAhospital2026-02-26

Coroner's Finding: Lowery, Nahuel Sebastian

41y · Male·Acute liver failure with contributing Castleman's disease

A 41-year-old Aboriginal man with HIV and Castleman's disease died from acute liver failure while on home detention. He had variable compliance with antiretroviral therapy, exacerbated by amphetamine use disorder and men…

infectious diseasesintensive careantiretroviral therapy
SAaged care2025-09-11

Coroner's Finding: Glenn, Millicent

89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…

An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…

general practicegeriatric medicinemedicationdiagnosticgentamicin
SAhome2024-06-28

Coroner's Finding: Evans, Caleb

0y · Male·unascertained, in an unsafe sleeping environment, on a background of respiratory…

Baby Caleb, aged 2 months, died on 30 November 2018 in an unsafe sleeping environment while his mother co-slept with him on a fold-out sofa in a squalid home. He had a concurrent respiratory tract infection. The coroner …

paediatricsgeneral practicesystemcommunication
SAhospital2024-05-22

Coroner's Finding: Kolega, Sime

54y · Male·multi-organ failure and sepsis complicating fulminant pneumonia with empyema (op…

A 54-year-old man died from sepsis and multi-organ failure secondary to fulminant pneumonia with empyema. He presented to his GP on 1 April 2021 with concerning signs including bilateral oedema, fever, and respiratory sy…

general practiceemergency medicinedelaysystemflixotide
SAhospital2024-03-27

Coroner's Finding: Collins, Jennifer Ann

30y · Female·tricuspid valve bacterial endocarditis

Jennifer Collins, a 30-year-old intravenous methylamphetamine user, died from tricuspid valve bacterial endocarditis on 6 September 2018. She presented to Noarlunga Hospital ED on 20 August 2018 with chest tightness, fev…

emergency medicinecardiologydiagnosticcommunicationmethamphetamine
SAhospital2022-10-27

Coroner's Finding: Rentoulis Dimitrios

79y · Male·Iatrogenic right ventricular injury complicating drainage of pericardial collect…

A 79-year-old man died from iatrogenic right ventricular injury sustained during attempted drainage of a post-operative pericardial effusion following coronary artery bypass grafting. During a minimally invasive sub-xiph…

cardiothoracic surgeryanaesthesiaproceduralwarfarin
SAhospital2022-04-14

Coroner's Finding: Esposito, Pasquale

76y · Male·combined effects of acute myocardial infarction and urosepsis

Pasquale Esposito, age 76, died in custody at Lyell McEwin Hospital from combined acute myocardial infarction and urosepsis. He had extensive cardiac history including prior MI, CABG, COPD, and recent stent placement. On…

cardiologyinfectious diseasesantibiotics
SA2021-11-25

Coroner's Finding: Hancott, Duncan John

56y · Male·urosepsis

Duncan John Hancott, aged 56, died in Mount Gambier Prison from urosepsis secondary to urinary tract infection caused by E. coli. He had significant comorbidities including hepatic cirrhosis, portal hypertension, and his…

infectious diseaseshepatologydiagnosticamitriptyline
SAhospital2021-06-30

Coroner's Finding: MOKETARINJA Anthea Ryder

42y · Female·multiple organ failure due to sepsis on a background of pneumonia, spontaneous b…

Anthea Ryder Moketarinja, a 42-year-old Aboriginal woman with advanced cirrhosis, died from multiple organ failure due to sepsis, pneumonia, spontaneous bacterial peritonitis, and end-stage liver disease. She was admitte…

general medicinepsychiatryantibiotics
SAhospital2020-12-18

Coroner's Finding: WALSH Patrick Lawrence

86y · Male·combined effects of acute myeloid leukaemia, acute renal failure and staphylococ…

Patrick Lawrence Walsh, aged 86, died in custody at Royal Adelaide Hospital from combined acute myeloid leukaemia, acute renal failure, and staphylococcal pneumonia. He had a significant medical history including ischaem…

haematologyinfectious diseasesdiagnosticdelay
SAhospital2020-07-09

Coroner's Finding: SHAW Laurel Jean

84y · Female·multi-organ failure arising from Staphylococcal septicaemia

Laurel Jean Shaw, aged 84, died from multi-organ failure secondary to Staphylococcal septicaemia. She was detained under a Mental Health Act order for Lewy Body Dementia when she developed MRSA pneumonia and sepsis on 15…

intensive carepsychiatry
SAhospital2020-07-02

Coroner's Finding: SWINGLER Yvonne Mary

86y · Female·multi-organ failure due to sepsis

An 86-year-old woman with dementia, recent stroke, and multiple comorbidities was admitted with acute delirium and paranoia, subsequently placed on an Inpatient Treatment Order. She developed sepsis secondary to staphylo…

psychiatryemergency medicinemorphine
SAhospital2020-06-18

Coroner's Finding: THOMPSON Wayne Robert McInnes

33y · Male·Multi-organ failure due to sepsis on a background of severe ischaemic cardiomyop…

Wayne Robert McInnes Thompson, aged 33, died from multi-organ failure due to sepsis complicated by severe ischaemic cardiomyopathy. He had a complex medical history including viral myocarditis, previous intestinal resect…

cardiologyintensive carewarfarin
SAhospital2020-05-21

Coroner's Finding: SOMMERVILLE Adam

73y · Male·metastatic small cell lung cancer and sepsis

A 73-year-old man with metastatic small cell lung cancer and sepsis died in Royal Adelaide Hospital while in prison custody. He had been sentenced in May 2015 and received appropriate oncology care including chemotherapy…

oncologyradiation oncologybuprenorphine
SAhospital2019-05-08

Coroner's Finding: JONES Melissa Irene

45y · Female·methicillin resistant staphylococcus aureus (MRSA) endocarditis of the mitral va…

A 45-year-old woman with chronic renal failure requiring dialysis and bipolar disorder died of MRSA endocarditis of the mitral valve. She was detained under a Mental Health Act order due to manic episodes and non-complia…

nephrologypsychiatrylithium
SAhospital2018-09-07

Coroner's Finding: MCBRIDE Peter James

86y · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer

An 86-year-old man died from multi-organ failure due to sepsis from a stage 4 sacral pressure ulcer after 61 days in a regional hospital. Critical failures included delayed pressure injury risk assessment (7 days overdue…

general practicegeriatric medicinediagnosticproceduralolanzapine
SAhospital2017-12-12

Coroner's Finding: HODGINS William Albert

95y · Male·multi-organ failure due to sepsis and general inanition on a background of advan…

William Albert Hodgins, aged 95, died of multi-organ failure due to sepsis and general inanition on a background of advanced vascular dementia and ischaemic heart disease. He was admitted under a Level 2 Inpatient Treatm…

psychiatrygeneral medicine
SAhospital2017-11-15

Coroner's Finding: BROADWAY Rita Ann

66y · Female·urinary tract infection with contributing hypertensive heart disease, diabetes m…

Rita Ann Broadway, 66, died from urinary tract infection on 2 January 2015, one day after presenting to Modbury Hospital Emergency Department with vaginal pain and signs of infection. She had a long-term indwelling cathe…

emergency medicineinfectious diseasesdiagnosticcommunicationparacetamol/codeine
SAhospital2017-04-07

Coroner's Finding: MAYELL Edward John

83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…

An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…

emergency medicinegeneral practicediagnosticmedicationceftriaxone

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