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SA2020-11-26

Coroner's Finding: KEN Kenneth Ngalatji

68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…

A 68-year-old Aboriginal man died by hanging in his cell at Yatala Labour Prison on 16 April 2015 while experiencing acute myocardial infarction. He was transferred to Yatala for urgent psychiatric assessment following t…

psychiatrycardiologydiagnosticcommunicationolanzapine
SAhospital2020-11-03

Coroner's Finding: ALLEN Wendy Elizabeth

75y · Female·general inanition and pneumonia on a background of end-stage dementia

75-year-old woman with end-stage mixed dementia (vascular and Alzheimer's) died from general inanition and pneumonia. She was detained under a Mental Health Act Inpatient Treatment Order due to severe aggression and beha…

psychiatrygeriatric medicinehydromorphone
SAhospital2020-11-03

Coroner's Finding: MARSHALL Daryl Grant

61y · Male·hospital acquired pneumonia complicating aorto-femoral bypass surgery for periph…

A 61-year-old man with peripheral vascular disease, alcohol dependence, and heavy smoking history underwent aorto-femoral bypass surgery. Post-operatively he developed hospital-acquired pneumonia, delirium from alcohol w…

vascular surgeryintensive care
SAhospital2020-11-03

Coroner's Finding: WHISKEY Louise Kitty

51y · Female·community acquired pneumonia

Louise Kitty Whiskey, a 51-year-old Aboriginal woman with chronic alcohol misuse, cirrhosis, and recurrent respiratory infections, died from community-acquired pneumonia at Royal Adelaide Hospital. She was admitted on 23…

intensive carepsychiatrysystemnoradrenaline
SAhospital2020-11-02

Coroner's Finding: BROWN Graham Douglas

79y · Male·combined cardiac, respiratory and renal failure as terminal events on a backgrou…

Graham Douglas Brown, a 79-year-old man with end-stage dementia, died at Noarlunga Hospital from combined cardiac, respiratory and renal failure. He was subject to a Level 2 Mental Health Act Inpatient Treatment Order at…

psychiatryemergency medicinemorphine
SAhospital2020-11-02

Coroner's Finding: DAVIES Brian

79y · Male·myocardial infarction

Brian Davies, 79, died of myocardial infarction while under an Inpatient Treatment Order for Alzheimer's dementia at Noarlunga Hospital. He presented with cognitive decline following his partner's death and developed agi…

geriatric medicinepsychiatrymedicationoxazepam
SAhospital2020-11-02

Coroner's Finding: HAUSLER Christopher Raymond

61y · Male·Creutzfeldt-Jakob disease

Christopher Raymond Hausler, a 61-year-old man, died from Creutzfeldt-Jakob disease (CJD) at the Royal Adelaide Hospital on 13 March 2018 while subject to a Level 2 Inpatient Treatment Order. He presented with rapidly pr…

general practiceneurologydiagnostic
SAhospital2020-11-02

Coroner's Finding: LAMB Dianne Patricia

67y · Female·disseminated adenocarcinoma of the colon

A 67-year-old woman with metastatic colorectal cancer developed multiple cerebral metastases causing marked behavioural changes (irritability, disinhibition, aggression). She was appropriately placed on Mental Health Act…

oncologypsychiatrydexamethasone
SAhospital2020-11-02

Coroner's Finding: MAGGS Eric Arthur

85y · Male·ischaemic heart disease

Eric Arthur Maggs, aged 85, died of ischaemic heart disease at Royal Adelaide Hospital. He was profoundly deaf from birth and had dementia. Admitted with acute chest pain and difficulty breathing, he became distressed an…

emergency medicinecardiologycefalexin
SAhospital2020-11-02

Coroner's Finding: MILOCCHI Guiseppe

90y · Male·pneumonia leading to atrial fibrillation leading to myocardial infarction

A 90-year-old man with lung cancer, dementia, and frontal lobe disease died from pneumonia leading to atrial fibrillation and myocardial infarction while on an inpatient mental health treatment order. He was admitted wit…

emergency medicinepsychiatryantibiotics
SAhospital2020-11-02

Coroner's Finding: NIXON Viola Daphne

92y · Female·decompensated congestive cardiac failure secondary to haemophilus influenzae low…

A 92-year-old woman with dementia, heart disease, and COPD died from decompensated congestive cardiac failure secondary to haemophilus influenzae lower respiratory tract infection. She was admitted to psychiatric care un…

psychiatryemergency medicine
SAhome2020-11-02

Coroner's Finding: TAYLOR Mervyn Maxwell

48y · Male·atherosclerotic cardiovascular disease

Mervyn Maxwell Taylor, aged 48, died suddenly at home from atherosclerotic cardiovascular disease with significant coronary artery stenosis (75-80%). He was on home detention bail at the time. He had no prior medical his…

pathologyforensic medicine
SAhospital2020-10-30

Coroner's Finding: VELT Hank Jakob

65y · Male·ischaemic and hypertensive heart disease with contributing acute cholecystitis (…

A 65-year-old man with hypertension presented with acute cholecystitis, underwent laparoscopic cholecystectomy, and initially recovered well. On post-operative day 7, he experienced chest pain radiating to his jaw. Two E…

general surgerycardiologydiagnosticcommunication
SAhome2020-10-12

Coroner's Finding: BABAKHANI Sina

21y · Male·heroin toxicity

A 21-year-old man died from heroin toxicity while on home detention bail. He had been engaged in a methadone program and psychological treatment for heroin addiction, PTSD, depression and anxiety since June 2015. Despite…

addiction medicinepsychiatryheroin
SA2020-10-12

Coroner's Finding: KEIRL Dennis Frank

63y · Male·metastatic carcinoma of the lung (small cell neuroendocrine carcinoma with poorl…

A 63-year-old male prisoner died from metastatic small cell lung cancer with adenocarcinoma features. Cancer was incidentally discovered during investigation of a deep vein thrombosis in October 2018, leading to one mont…

oncologygeneral medicinewarfarin
SAhospital2020-10-12

Coroner's Finding: MANSVELDERS Henri Martinus Bernardus

79y · Male·Atherosclerotic right internal carotid artery occlusion with resultant ischaemia…

A 79-year-old man with significant cardiovascular disease history (prior MI, triple bypass, hypertension, hypercholesterolaemia) was admitted to psychiatric care under an Inpatient Treatment Order following suicidal idea…

psychiatryneurologymorphine
SAhospital2020-10-12

Coroner's Finding: USHER Peter Michael

56y · Male·hypoxic ischaemic encephalopathy following insulin and benzodiazepine overdose

A 56-year-old man with depression, known to close friends but not formally disclosed to healthcare providers, deliberately ingested temazepam tablets accumulated over time and insulin stolen from his mother on 10-11 Nove…

anaesthesiapsychiatrytemazepam
SAmental health2020-09-22

Coroner's Finding: NOONAN Ricky Dale

54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking

A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to…

psychiatryemergency medicinecommunicationsystemhaloperidol
SAhospital2020-08-04

Coroner's Finding: WILLMETT Laura Angela

0y · Female·hypoxic ischaemic encephalopathy secondary to intrapartum hypoxia

A 2-day-old neonate, Laura Angela Willmett, died from hypoxic-ischaemic encephalopathy following intrapartum hypoxia. She was born by emergency caesarean section after a planned vaginal birth after caesarean (VBAC) at a …

obstetricsmidwiferydiagnosticcommunicationparacetamol/codeine
SAhospital2020-07-16

Coroner's Finding: GRAEFE Phillip Brian

62y · Male·Multi-organ failure due to paraquat ingestion

A 62-year-old man with diabetes, renal failure, and hypertension died from multi-organ failure following intentional ingestion of approximately 100-150ml of paraquat. He had recently assumed sole responsibility for the f…

toxicologyemergency medicineparaquat
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