Coronial

537 results for sepsis

VICaged care2022-11-23

Finding into death of Lucio Chiussi

89y · Male·septicaemia due to infected groin wound, femoropopliteal bypass in a man with mu…

…e wound suddenly worsened to a 1cm deep blister. The patient was admitted to hospital on 13 September with sepsis and died the following day. The coroner found the death may have been preventable with earlier specialist …

geriatric medicinevascular surgerydiagnosticcommunicationoral antibiotics
WAhospital2023-12-13

Inquest into the Death of Ashleigh Rebecca HUNTER

26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia

…pain warranting Code 2; (3) severe pain coupled with tachycardia, hypothermia and early collapse warranted sepsis consideration despite absent fever and rash; (4) drug use disclosure may have created cognitive bias, with…

emergency medicineinfectious diseasesdiagnosticsystemMDMA
VIChomeNew2026-06-10

Finding into death of Laura Claire Brady

41y · Female·Aspiration pneumonia complicating an ischaemic stroke in a woman with epilepsy, …

… where investigations revealed a subacute right middle cerebral artery ischaemic stroke and pneumonia with sepsis. She was appropriately admitted to the Neurology Department, where she received diagnostic imaging (CT, MR…

neurologyemergency medicine
WAhospital2026-03-26

Inquest into the Death of Sandipan DHAR

1y · Male·Complications of acute lymphoblastic leukaemia

Sandipan Dhar, 21 months old, died from undiagnosed acute lymphoblastic leukaemia (ALL) complicated by sepsis and pneumonia on 24 March 2024. After three weeks of intermittent fever, he attended his GP three times an…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
VIChospital2017-05-25

Finding into death of Finding Baby Ahmed

0y · Male·Urosepsis and renal failure in a child with acute on chronic pyelonephritis seco…

…ys. He was assessed by multiple GPs and presented to the ED at Werribee Mercy Hospital with clear signs of sepsis and decompensation. The ED diagnosis of bronchiolitis was inappropriate; examination findings (normal ches…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
NThospital2018-09-21

Inquest into the death of Henry George Wilson aka Albert Wilson

77y · Male·sepsis due to retroperitoneal collection after biliary stent insertion on a back…

A 77-year-old Aboriginal man died from sepsis following a percutaneous transhepatic cholangiography (PTC) procedure that perforated his duodenum. Critic…

general surgeryradiologydiagnosticcommunicationpiperacillin/tazobactam
SAhospital2010-12-30

Coroner's Finding: D'AGOSTINO Antonia

59y · Female·sepsis due to faecal peritonitis due to perforation of sigmoid colon complicatin…

A 59-year-old woman died from sepsis due to faecal peritonitis following a bowel perforation during laparoscopic oophorectomy for a benign ovar…

gynaecologygeneral surgerydiagnosticdelaypethidine
VIChospital2017-11-20

Finding into death of Graeme Harold Griffiths

65y · Male·Severe neutropenic sepsis and multi-organ failure secondary to severe mucositis …

A 65-year-old man with stage 3 rectal cancer died from severe neutropenic sepsis and multi-organ failure secondary to probable dihydropyrimidine dehydrogenase (DPD) deficiency when treate…

oncologyradiation oncologydelaycapecitabine
WAhospital2024-08-28

Inquest into the Death of Matthew John PICKIN

56y · Male·Complications, including sepsis, of left leg infection (operated), in a man with…

Matthew John Pickin, a 56-year-old prisoner with metastatic lung adenocarcinoma, died from sepsis complicating a left leg infection. His lung cancer was appropriately investigated following haemoptysis in…

respiratory medicineoncologysystemdexamethasone
TAShospital2024-08-05

Coroner's Finding: Whitney, David Ian

73y · Male·sepsis due to ischemic gut due to occlusion of the superior mesenteric artery

A 73-year-old man presented with acute severe abdominal pain caused by superior mesenteric artery (SMA) occlusion. Initial CT angiogram at 12:30am was reported as normal; the SMA occlusion was not identified until 4:45am…

emergency medicineradiologydiagnosticcommunication
TAShospital2021-08-20

Coroner's Finding: LA

67y · Male·acute gastrointestinal haemorrhage complicating peptic ulcer of the duodenum wit…

… practitioners failed to recognize this omission; (3) Post-9 August treatment was appropriate, but earlier sepsis recognition and continued acid suppression might have prevented the final catastrophic bleed. Clinicians s…

general surgeryintensive carediagnosticmedicationrabeprazole
QLDhospital2016-02-22

Robertson, Elsie - Non-inquest findings

0y · Female·Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, s…

… weeks. She died 9 hours 43 minutes after birth from combined hypoxic-ischaemic encephalopathy and E. coli sepsis secondary to chorioamnionitis. Critical clinical lessons include: (1) confusion over twin nomenclature del…

obstetricsneonatologycommunicationsystemmagnesium sulphate
WAhospital2022-06-23

Inquest into the Death of Lee MILCHERDY

75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…

Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the p…

gastroenterologygeneral surgerycommunicationdiagnostic
NSWhospital2019-10-25

Inquest into the death of Peter SMITH

67y · Male·Gas gangrene with antecedent cause of Clostridium septicum septicaemia

Peter Smith, 67, presented to Cooma Hospital with severe leg muscle cramps and pain on 6 February 2018. Despite appropriate pain management and initial investigation suggesting rhabdomyolysis, he rapidly deteriorated and…

emergency medicinegeneral practicesystemmorphine
WAhospital2018-06-14

Inquest into the Death of Anne RZEPCZYNSKI

59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…

59-year-old woman died from intra-abdominal sepsis, multi-organ failure and bowel perforation following median hepatectomy for cholangiocarcinoma. Key clinic…

general surgeryintensive carediagnosticdelayantibiotics
NSWcommunity2025-04-04

Inquest into the death of RD

7y · Female·Group A Streptococcus (Streptococcus pyogenes) pneumonia with sepsis

A 7-year-old previously healthy girl died from Group A Streptococcus pneumonia with sepsis after paramedics failed to transport her to hospital despite recording a severely elevated heart rate (172…

emergency medicineparamedicinediagnosticcommunicationparacetamol
WAhospital2021-11-29

Inquest into the Death of Miss T (Name Subject to Suppression Order)

16y · Female·acute abdominal obstruction secondary to adhesions associated with severe pelvic…

…(5) lack of a short-stay observation unit at the hospital. The coroner emphasised heightened vigilance for sepsis in young Aboriginal people presenting with abdominal pain, and the need for improved access to sexual heal…

emergency medicinegeneral practicediagnosticsystemcannabis
SAhospital2000-07-21

Coroner's Finding: HOWIESON Julie Ann

43y · Female·sepsis secondary to extensive acute peritonitis following perforation of small b…

43-year-old woman died from sepsis and necrotising fasciitis following small bowel perforation during laparoscopic tubal ligation. She was at…

gynaecologyanaesthesiadiagnosticdelay
VIChospital2015-02-12

Finding into death of Mary Mulqueen

57y · Female·small bowel ischaemia; distal gastrectomy

…ttempts at nutritional support. However, the immediate cause of death was acute small bowel ischaemia with sepsis in August 2009, and the specific trigger for this acute deterioration could not be determined. While the s…

general surgerygastroenterologyproceduraldiagnosticesomeprazole
NThospital2017-04-07

Inquest into the death of Gabby Wanambi

11y · Female·Acute Staphylococcal Septicaemia due to suppurative arthritis of the left ankle

…ailures included: no requirement for doctor assessment of ED patients after hours; inadequate staffing; no sepsis recognition protocol implementation despite a similar preventable death two years earlier; and poor clinic…

emergency medicineinfectious diseasesdiagnosticcommunicationparacetamol
110111227

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