Coronial

226 results for type 2 diabetes mellitus

VICcommunity2022-01-20

Finding into death of YLM

78y · Male·Ruptured abdominal aortic aneurysm

A 78-year-old man died from rupture of a previously undiagnosed 7.1cm abdominal aortic aneurysm. A CT scan ordered for suspected renal colic incidentally discovered the aneurysm and recommended vascular review. The GP ap…

general practiceradiologycommunicationsystem
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 …

ophthalmologyanaesthesiadiagnosticcommunicationlidocaine
WAhospital2020-04-24

Inquest into the Death of Hassan BECHARA

52y · Male·ischaemic heart disease

Hassan Bechara, a 52-year-old prisoner, died from ischaemic heart disease in July 2017. He had complex cardiac history including dilated cardiomyopathy, triple-vessel coronary disease, and previous cardiac procedures. Cl…

cardiologyemergency medicinedelaysystematorvastatin
VICaged care2020-01-30

Finding into death of Adele Di Quinzio

86y · Female·Sepsis complicating sacral decubitus ulceration in the setting of recent surgica…

Mrs Di Quinzio, an 86-year-old woman with multiple comorbidities, was discharged from hospital to a supported residential service (SRS) after hip fracture surgery. She required two-person assistance for mobility and was …

geriatric medicineorthopaedic surgerysystemcommunicationcefalexin
SA2021-05-28

Coroner's Finding: GIBSON Ian Keith

46y · Male·congestive cardiac failure due to cardiomyopathy and coronary artery atheroscler…

…oronary artery atherosclerosis while in police custody. He was correctly categorized as High Needs due to diabetes, seizure history, and alcohol dependency, and appropriate nursing assessment was conducted on arrival. Ho…

cardiologygeneral practiceproceduralcommunication
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 after left…

urologysurgeryproceduraldiagnosticmetaraminol
NSWcustodial setting (correctional facility) with death at hospital2025-07-23

Inquest into the death of James Cunneen

60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…

James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding du…

general practiceinfectious diseasesdiagnosticmedicationpantoprazole
NSWhospital2022-08-17

Inquest into the death of Robert Bischard

75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…

…ld man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coroner found that surgery shoul…

orthopaedic surgerycardiologydiagnosticsystemfurosemide
QLDhome2012-11-14

Galeano, Antonio Carmelo

39y · Male·Excited delirium, probably caused by amphetamine toxicity-induced psychosis. Dea…

Antonio Carmelo Galeano died in police custody on 12 June 2009 after a protracted struggle and multiple taser activations. He had acute amphetamine toxicity and was displaying excited delirium—a high-risk medical emergen…

emergency medicinepsychiatryproceduralcommunicationamphetamine
TAShospital2023-10-11

Coroner's Finding: Jones, Emily Margaret Rose

82y · Female·traumatic closed head injury (subdural haematoma) resulting from a fall from sta…

Mrs Emily Jones, 82, died from subdural haematoma following an unwitnessed fall at Royal Hobart Hospital on 15 November 2021. She was admitted five days after discharge from Hobart Private Hospital where she was treated …

cardiologyemergency medicinemedicationcommunicationmetoprolol
VIChospital2022-02-25

Finding into death of Joseph Cardona

49y · Male·haemopericardium secondary to ruptured aortic dissection

Joseph Cardona, 49, died from ruptured aortic dissection with haemopericardium. He presented to the ED twice within 24 hours with severe central chest pain radiating to jaw, neck, and back, associated with hypertension. …

emergency medicinecardiologydiagnosticcommunicationoxycodone
QLDhospital2019-07-24

Mr P - Non-inquest findings

47y · Male·Pulmonary thrombo-embolism secondary to deep vein thrombosis in setting of morbi…

A 47-year-old man with morbid obesity presented with respiratory failure, productive cough, and calf swelling. His GP appropriately suspected both pneumonia and pulmonary embolism (PE), requesting urgent CTPA. At Townsvi…

intensive careemergency medicinediagnosticcommunicationheparin
VIChospital2025-04-17

Finding into death of Graeme William Dimsey

62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…

A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…

orthopaedic surgeryinfectious diseasesdiagnosticproceduralceftriaxone
VIC2022-07-11

Finding into death of Mladen Jovanoski

57y · Male·Consequences of multiple injuries (from fall from elevated walkway)

Mladen Jovanoski, a 57-year-old remand prisoner, died from head injuries sustained after falling from a prison walkway on 11 April 2018. He had suspected metastatic thyroid cancer requiring urgent biopsy at a tertiary ho…

endocrinologyoncologysystemcommunication
WAmental health2019-05-22

Inquest into the Death of Christopher John DEBNAM

40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…

Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensat…

psychiatryrespiratory medicinediagnosticcommunicationhaloperidol
NSWaged care2025-01-24

Inquest into the deaths at Newmarch House

Unknown·COVID-19 infection with various comorbidities as contributing factors

This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…

geriatric medicineinfectious diseasessystemdiagnosticmorphine
SAhospital2018-09-07

Coroner's Finding: MCBRIDE Peter James

86y · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer

An 86-year-old man died from multi-organ failure due to sepsis from a stage 4 sacral pressure ulcer after 61 days in a regional hospital. Critical failures included delayed pressure injury risk assessment (7 days overdue…

general practicegeriatric medicinediagnosticproceduralolanzapine
QLDhospital2016-02-29

Mr B - Non-inquest findings

84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…

An 84-year-old man with multiple comorbidities was prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed,…

cardiologyhaematologymedicationcommunicationrivaroxaban
VIChospital2025-08-04

Finding into death of Winifred Jean Carpenter

82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…

Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…

general surgerycolorectal surgerydiagnosticcommunication
TASmental health2017-11-17

Coroner's Finding: Smith, Molly Jessie

75y · Female·pyelonephritis and pneumonia

Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …

psychiatrygeneral practicediagnosticdelaycefalexin

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