Coronial
WAhospital2019-05-31

Inquest into the Death of Aurelio Monterlegre CRUZ

80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…

…man with complex medical conditions including chronic renal failure, ischaemic heart disease, diabetes, and COPD, died of bronchopneumonia complicating terminal palliative care while a sentenced prisoner. He had consiste…

nephrologypalliative carecommunicationdelayinsulin
NSWhospital2023-03-09

Inquest into the death of William Edmunds

79y · Male·complications of peritonitis

A 79-year-old man with multiple comorbidities presented with a perforated bowel requiring emergency Hartmann's procedure. The operating surgeon, Dr L.-Ming Schmidt, made a catastrophic surgical error by exteriorising the…

general surgeryintensive careproceduraldiagnosticmorphine
VIChospital2018-06-14

Finding into death of Ian John Gilbert

77y · Male·Complications of methotrexate toxicity in a man with chronic renal impairment, c…

A 77-year-old man with chronic kidney disease, COPD, and mild cardiac failure died from methotrexate toxicity after a GP prescribed it at an inappropriate dail…

general practicepharmacydiagnosticmedicationmethotrexate
QLDhospital2023-06-26

Searle, William Edward

74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …

William Searle, a 74-year-old prisoner, died from aspiration of gastric contents following a Whipple procedure for recurrent ampullary adenoma. The clinical lessons involve recognition of gastroparesis risk in high-risk …

general surgeryintensive carediagnosticcommunicationadrenaline
NThospital2019-04-16

Inquest into the death of Ali Achmadun Djawas

70y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …

Ali Djawas, a 70-year-old Indonesian-born man with comorbidities (hypertension, diabetes, COPD), underwent elective right hemicolectomy on 13 March 2017 for a suspicious ileo-caecal lesion. Biopsies wer…

colorectal surgerygeneral surgerydiagnosticcommunicationmethylnatrexone
QLDhospital2018-08-20

RD - Non-inquest findings

64y · Male·Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia…

RD, a 64-year-old man with diabetes, amputation, and COPD, presented to a private hospital emergency department with suspected sepsis (vomiting, diarrhoea, hypotensi…

emergency medicineintensive carediagnosticmedicationintravenous normal saline
NT2025-08-29

Inquest into the death of Raylene Dick, David Hardy and Karen Bading

46y · Female·Hepatic encephalopathy due to decompensated Child-Pugh C cirrhosis and meningiti…

…gs. Ms Dick died from rapidly progressive melioidosis. David Hardy died from respiratory failure related to COPD. Karen Bading, a 46-year-old Aboriginal woman with serious chronic conditions (cirrhosis, lupus, asthma), d…

infectious diseasesintensive carediagnosticsystem
VIChospital2024-10-29

Finding into death of Shane Hughes

40y · Male·Acute hepatic and renal failure in the setting of postoperative haemorrhage foll…

A 40-year-old man with obesity, COPD, diabetes and hypertension died from acute hepatic and renal failure following postoperative haemorrhage af…

urologysurgeryproceduraldiagnosticmetaraminol
VIChospital2022-08-19

Finding into death of Ruth Ann McKenna

62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…

…ld woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy for an endome…

gynaecologyanaesthesiadiagnosticsystemmetaraminol
WA2022-06-21

Inquest into the Death of Ashley Adrian LANE

56y · Male·acute exacerbation of chronic obstructive pulmonary disease (bronchial asthma) i…

Ashley Adrian Lane, a 56-year-old Aboriginal man from the Ngaanyatjarra Lands, died in custody at Kalgoorlie Regional Hospital from acute exacerbation of chronic obstructive pulmonary disease (asthma). He was a remand pr…

respiratory medicineemergency medicinediagnosticcommunicationsalbutamol
QLDhospital2017-06-22

PS - Non-inquest findings

68y · Female·Coronary heart disease

A 68-year-old woman with diabetes, hypertension, hypercholesterolaemia, COPD and chronic renal failure presented with chest pain and dyspnoea. She was admitted with suspected congestiv…

cardiologyemergency medicinediagnosticcommunicationfurosemide

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