Coronial

229 results for pulmonary hypertension

TASaged care2018-10-30

Coroner's Finding: Dent, Freda Lillian Florence

85y · Female·ischaemic heart disease due to stenosis of coronary bypass grafts

An 85-year-old woman with significant cardiac history (prior coronary artery bypass graft) presented with gastrointestinal symptoms. Her GP ceased rosuvastatin without direct communication to nursing staff. Care staff id…

general practicegeriatric medicinecommunicationsystemrosuvastatin
SAhospital2006-05-19

Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…

77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural ta…

cardiologycardiothoracic surgerydiagnosticproceduralramipril
VICaged care2019-10-14

Finding into death of Grant White

65y · Male·Cardiomegaly

Grant White, a 65-year-old man with cardiomegaly and severe mitral regurgitation living in Department of Health and Human Services disability accommodation, died from cardiomegaly on 11 September 2017. Two days before hi…

cardiologygeneral practicesystemcommunicationhaloperidol
WAhospitalPodcast2017-05-03

Inquest into the Death of Edith Catherine BEE

80y · Female·Gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm …

An 80-year-old woman with multiple comorbidities (COPD, renal impairment, cardiac disease) underwent complex endoluminal repair of a thoracoabdominal aortic aneurysm at a private hospital. The procedure required use of C…

vascular surgerygeneral surgeryproceduralsystem
WAhospital2014-10-17

Inquest into the Death of Gillian Hanson

62y · Female·hyponatremia (low sodium level 114mmol/L) resulting in seizure, with aspiration …

A 62-year-old woman with chronic schizophrenia died from hyponatremia (sodium level 114mmol/L) resulting in seizure and aspiration during involuntary psychiatric admission. She had been on escitalopram (SSRI) for depress…

psychiatrygeneral practicediagnosticescitalopram
VIChospital2025-08-13

Finding into death of Jordan Thomas Alexander McDonald

0y · Male·complications of extreme prematurity in the setting of precipitant premature bre…

Jordan was born at 25 weeks 4 days gestation in an emergency department following precipitant breech labour with a circumvallate placenta. He received appropriate initial resuscitation but was administered 10 times the p…

neonatologyobstetricsmedicationdiagnosticmorphine
VIChome2016-02-29

Finding into death of Yamini Bhadrayu Patel

48y · Female·Ischaemic brain injury secondary to toxicity to tramadol and temazepam

A 48-year-old woman died from ischaemic brain injury caused by overdose of tramadol and temazepam. She was found unresponsive at home on 10 October 2009 after consuming these medications. Her family and GP Dr D. failed t…

general practiceintensive carediagnosticdelaytramadol
VIChospital2018-06-18

Finding into death of Giuseppe Costa

75y · Male·Right haemothorax complicating intercostal catheter insertion for the treatment …

Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainag…

respiratory medicinegeneral medicineproceduralcommunicationnebivolol
VIChome2021-02-24

Finding into death of AAC

29y · Male·Combined drug toxicity (pregabalin, dihydrocodeine, tramadol, temazepam, lorazep…

A 29-year-old man with class III obesity died from combined drug toxicity involving pregabalin, dihydrocodeine, tramadol, temazepam, and lorazepam. He engaged in prescription medication abuse over 12 months, consulting a…

general practicetoxicologydiagnosticsystempregabalin
NTaged care2020-12-18

Inquest into the death of Barbara Francis

78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…

Barbara Francis, a 78-year-old resident with dementia at Pearl Supported Care in the dementia unit (Dinah), was punched by another resident (Mr A) on 4 September 2018 and fell backward onto her right hip, sustaining an o…

geriatric medicineorthopaedic surgerysystemcommunication
QLDhome2025-07-15

Inquest into the death of Daniel Thomas Wright

8y · Male·prematurity-associated lung and bowel disease

Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associate…

neonatologypaediatricsdiagnosticcommunication
SAhospital2008-08-22

Coroner's Finding: CARTER Kenneth Morton

76y · Male·ruptured abdominal aortic aneurysm

Kenneth Carter, 76, died from a ruptured abdominal aortic aneurysm (AAA) on 8 June 2005. He had presented to Flinders Medical Centre Emergency Department on 1 June 2005 with back pain, hypotension (90/65 mmHg), and two e…

emergency medicinegeneral medicinediagnosticsystemwarfarin
NSWhome2018-06-08

Inquest into the death of BL GN and D G

Female·Sudden Unexpected Death in Infancy (SUDI), otherwise undetermined

Two infants died suddenly and unexpectedly. The first child died at home at 3 months of age in an unsafe sleeping environment with multiple soft items in her cot; the second died in temporary care at 19 days of age. Both…

paediatricsneonatologysystemdelayice/methamphetamine
SAhospital2015-03-06

Coroner's Finding: SIMOS Theodoras Joannas

48y · Male·undetermined

A 48-year-old man with schizoaffective disorder, poorly controlled diabetes, sleep apnoea, obesity and cardiomegaly died unexpectedly at a rural hospital following acute psychotic agitation. He had absconded from a menta…

psychiatrygeneral practicesystemdelayhaloperidol
WAhospital- 27 May 2014

Inquest into the Death of Julissa Teresa GILBERT

57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of …

A 57-year-old woman with COAD, hypertension, and unrecognized severe coronary atherosclerosis presented with appendicitis. Surgery was performed by…

anaesthesiasurgerydiagnosticcommunicationaramine
NSWhospital2025-08-14

Inquest into the death of Wilfred Whippy Williams

45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia

A 45-year-old Aboriginal man with poorly managed diabetes and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs i…

emergency medicineendocrinologycommunicationdiagnosticmetformin
ACThospital2025-04-09

Inquest Into The Death Of Peter Hanisch

69y · Male·thoracic aortic aneurysm with dissection

…t was misread. Over the subsequent three days, clinicians pursued alternative diagnoses (stroke, sepsis, pulmonary embolism) based on the incorrect CT report. The coroner found that had the dissection been promptly diag…

radiologyemergency medicinediagnosticsystem
VICaged care2022-11-30

Finding into death of Ian Dunlop

74y · Male·Pericarditis post aortic valve surgery with large pericardial effusion leading t…

Ian Dunlop, a 74-year-old man, died from pericarditis with large pericardial effusion and tamponade four days after aortic valve replacement surgery. Post-operative imaging showed a small pericardial effusion, considered…

cardiothoracic surgerycardiologycommunicationsystemapixaban
VIChospital2021-02-26

Finding into death of Ian Fraser

68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…

Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…

respiratory medicinecardiothoracic surgerymedicationsystemapixaban
NThospital2026-01-09

Inquest into the death of C Guyula

49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …

A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical fa…

anaesthesiasurgeryproceduralmedicationfentanyl

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