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ACTmental health2023-06-27

Inquest into the death of MERREN ELIZABETH BARTLEY

67y · Female·ischaemic heart disease

Merren Elizabeth Bartley, a 67-year-old woman with schizophrenia managed with clozapine and multiple comorbidities including coronary artery disease, died of ischaemic heart disease while an inpatient at a mental health …

psychiatrycardiologyclozapine
VIC2023-06-22

Finding into death of Cherie Virginia Pearl Guest

61y · Female·Diffuse alveolar damage in a woman with restrictive lung disease following catar…

A 61-year-old woman with severe restrictive lung disease, obesity, cardiac failure, and diabetes underwent cataract surgery at a private day surgery centre on 13 August 2018. She was unable to lie flat and became hypoxic…

ophthalmologyanaesthesiadiagnosticcommunicationlidocaine
TAShospital2023-06-13

Coroner's Finding: HN de-identified

83y·cardiac tamponade due to haemopericardium resulting from traumatic parietal peri…

An 83-year-old woman presented to the ED with chest pain and was found to have a pericardial effusion. She underwent an aortic angiogram but critical investigations including echocardiography were not clearly documented.…

emergency medicinecardiologyproceduralsystem
VICcommunity2023-06-05

Finding into death of Brad Anthony Godressi

40y · Male·Cardiomyopathy in the setting of immersion and amphetamine use

Brad Godressi, a 40-year-old man with end-stage dilated cardiomyopathy recently discharged against medical advice from ICU, died from cardiomyopathy in the setting of immersion and amphetamine use while operating a boat …

cardiologyintensive caresystemdelayamphetamine
TAShospital2023-05-31

Coroner's Finding: Richardson Rebecca Eileen

29y · Female·acute myocardial infarction due to stenotic coronary vessel (left anterior desce…

Rebecca Richardson, a 29-year-old with type 1 diabetes and coronary artery disease, died of acute myocardial infarction on 7-9 May 2019. She presented to NWRH ED on 6 May with abdominal pain and vomiting, initially attri…

emergency medicinecardiologydiagnosticcommunicationinsulin
VIChospital2023-05-30

Finding into death of Thelma Annie Ogilvy

90y · Female·abdominal sepsis complicating perforated diverticular abscess of the sigmoid col…

Thelma Annie Ogilvy, a 90-year-old woman from rural Victoria, died from abdominal sepsis complicating a perforated diverticular abscess. She presented with bowel obstruction requiring laparotomy on 21 October 2019, was d…

general surgerycolorectal surgeryapixaban
TAS2023-05-22

Coroner's Finding: Hyde-Wyatt, Michael Phillip

61y · Male·Pulmonary aspiration of gastric contents (post seizure) due to chronic communica…

Michael Phillip Hyde-Wyatt, aged 61, died from pulmonary aspiration of gastric contents following a seizure. He had chronic communicating hydrocephalus and encephalomalacia. At 1:30am, support worker Julie Magrath observ…

general practiceneurologycommunicationdelay
ACThospital2023-05-19

Inquest into the death of NICOLE LOUISE ABBOTT

43y · Female·Complications of morbid obesity, including progressive respiratory and cardiac f…

Nicole Abbott, 43, died from complications of morbid obesity (BMI 54.4) including progressive respiratory and cardiac failure, exacerbated by smoking and obstructive sleep apnoea. She was subject to a Psychiatric Treatme…

psychiatrycardiologyzuclopenthixol
SA2023-05-12

Coroner's Finding: Morrison, Wayne Fella

29y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to out of hospital …

Wayne Fella Morrison, a 29-year-old Aboriginal man with undiagnosed coronary artery disease (70% stenosis of right coronary artery), died following cardiac arrest during his detention at Yatala Labour Prison. After attac…

emergency medicineintensive caresystemdelay
NSWhospital2023-05-09

Inquest into the death of Harriet Ostler

1y · Female·sudden cardiac death on a background of rhinovirus infection

Harriet Ostler, a 19-month-old toddler, was admitted to Port Macquarie Base Hospital with viral respiratory symptoms and died from sudden cardiac death due to underlying myocarditis/cardiomyopathy precipitated by rhinovi…

paediatricsemergency medicinediagnosticcommunicationsalbutamol
TAShospital2023-05-05

Coroner's Finding: Pedler, Anne Helen

71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis

71-year-old woman presented to ED with signs of circulatory failure (hypotension, tachycardia, tachypnoea, hypoxia) and progressive leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pulmonary emb…

emergency medicinecardiologydiagnosticdelaycannabis oil
NSW2023-05-05

Inquest into the death of John Cribb

67y · Male·Haemopericardium arising from a ruptured aorta (aortic dissection)

John Cribb, a 67-year-old man with known cardiac disease (coronary artery disease, aortic regurgitation, hypertension), died in custody from haemopericardium due to ruptured aortic dissection. He had signed a not-for-res…

cardiologypsychiatrysystem
TAShome2023-05-01

Coroner's Finding: Koeter, Jacqueline Francis

59y · Female·Global hypoxic brain injury due to mixed drug toxicity, specifically alprazolam …

A 59-year-old woman with a 30-year history of alprazolam dependence for anxiety disorder died from global hypoxic brain injury following cardiac arrest caused by mixed drug toxicity, with alprazolam levels in the fatal r…

general practicepsychiatryalprazolam
NSWhome2023-04-26

Inquest into the death of AX

70y · Female·Cause of death could not be determined - available evidence does not allow a fin…

A 70-year-old woman died unexpectedly at home in August 2017. Initially certified as hypertensive heart disease without autopsy, the death was later investigated as a potential homicide following allegations by her forme…

forensic medicinecardiologysystemdelaycandesartan
WAhospital2023-04-17

Inquest into the Death of Edward Ivan AFRICH

64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …

Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…

respiratory medicinecardiologycommunicationsystemthiamine
NSW2023-04-17

Inquest into the death of John Dodd

71y · Male·Ischaemic heart disease

John Charles Dodd, a 71-year-old man with known coronary ischaemic syndrome and hypertension, died of ischaemic heart disease while in custody at Geoffrey Pearce Correctional Centre. Autopsy revealed severe atherosclerot…

cardiologyforensic medicinemetoprolol
WAhospital2023-03-30

Inquest into the Death of Hugh WARD

89y · Male·Complications of cerebrovascular accident (stroke); specifically a catastrophic …

Hugh Ward, an 89-year-old sentenced prisoner, died from complications of stroke following an embolic cerebrovascular accident at Sir Charles Gairdner Hospital. While incarcerated, Mr Ward had multiple comorbidities inclu…

neurologycardiologycommunicationsystemwarfarin
VIC2023-03-20

Finding into death of Keanne Liza Whittam

43y · Female·Hypoxic ischaemic encephalopathy secondary to out of hospital cardiac arrest due…

43-year-old woman with severe, undiscovered coronary artery atherosclerosis died from out-of-hospital cardiac arrest while in police custody at Dame Phyllis Frost Centre. She had presented to ED 5 months earlier with leg…

cardiologyemergency medicinediagnosticheroin
VIChospital2023-03-16

Finding into death of Reginald William Griggs

84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …

An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…

oncologyENT surgerycommunicationsystemhydromorphone
NThospital2023-03-15

Inquest into the death of Janelle Pamkal

35y · Female·aortic dissection with associated acute aortitis

A 35-year-old Aboriginal woman with schizoaffective disorder presenting with acute psychosis and chest pain was appropriately referred for psychiatric assessment and retrieval. CareFlight transport was timely and the rec…

emergency medicinepsychiatryolanzapine
19101149

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