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VIC2024-09-04

Finding into death of Jing Hui Chen

49y · Male·Traumatic head injury sustained in a fall from the roof of a work vehicle

A 49-year-old air conditioning contractor died from traumatic head injury sustained when he fell from the roof of his work van while securing equipment. He was working at height without a harness or fall protection, and …

emergency medicineintensive caresystem
TAShome2024-08-29

Coroner's Finding: De-identified PT

14y · Male·Brain infarction caused by hypoxia following self-inflicted hanging by rope liga…

PT was a 14-year-old boy with a history of anorexia nervosa and bulimia who died by hanging in April 2022. He had been discharged from eating disorder treatment in November 2021 after maintaining appropriate weight. In t…

psychiatrypaediatricssystem
WAmental health2024-08-28

Inquest into the Death of Peter Jonathon Rex BOLTON

36y · Male·ligature compression of the neck (hanging)

A 36-year-old man with schizoaffective disorder, traumatic brain injury, and substance use disorder died by ligature while an involuntary inpatient in a locked mental health ward. He was on hourly observations and had re…

psychiatryemergency medicinehaloperidol
VIChospital2024-08-21

Finding into death of Hayley Michelle Impey

50y · Female·Aspiration pneumonia, with epilepsy with frequent seizures as contributory cause

Hayley Michelle Impey, aged 50, died from aspiration pneumonia complicated by epilepsy with frequent seizures. She presented with status epilepticus requiring intubation and transfer to a tertiary hospital. She was extub…

emergency medicineintensive careclonazepam
VIChospital2024-08-19

Finding into death of Matilda Ruby Armstrong

1y · Female·viral respiratory tract infection (Parainfluenza and Respiratory Syncytial Virus…

Matilda Armstrong, a 12-month-old previously well child, died from viral respiratory tract infection (Parainfluenza and RSV) complicated by Streptococcus pyogenes sepsis following recent COVID-19 infection. She presented…

emergency medicinepaediatricsdelaysystemparacetamol
VIChospital2024-08-14

Finding into death of Gayle Dianne Ireland

63y · Female·Sepsis with multiorgan failure in the setting of limb cellulitis complicating a …

A 63-year-old woman with multiple comorbidities (obesity, chronic lung disease, obstructive sleep apnoea, prior cerebrovascular disease with hemiparesis) sustained a 4cm laceration to her right shin from a motorised whee…

emergency medicineintensive carediagnosticdelayceftriaxone
VICmental health2024-08-09

Finding into death of Con Kostantinou

63y · Male·Unascertained - natural causes. Cardiac arrest with secondary hypoxic-ischaemic …

A 63-year-old man with bipolar affective disorder, obstructive sleep apnoea, prostatic hyperplasia, and emphysema was admitted involuntarily to Northern Hospital on 24 March 2024 after exhibiting delirium and mania with …

psychiatrygeneral medicinediazepam
VIChospital2024-08-07

Finding into death of Georgios Stamkos

68y · Male·Complications of a witnessed airway obstruction from food bolus in a man with dy…

A 68-year-old man with dysphagia and bipolar disorder died from airway obstruction and aspiration pneumonia after choking on a sandwich brought by his wife during a supervised hospital meal. He had been admitted with wor…

psychiatryspeech pathologyrisperidone
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
QLDhospital2024-07-30

PATELESIO, Etevise

29y · Female·Hypoxic-ischaemic encephalopathy due to cardiac arrest of undetermined cause

A 29-year-old woman with multiple comorbidities (Turner syndrome, type 1 diabetes, end-stage renal disease) presented to the ED in acute behavioural disturbance, requiring physical and chemical restraint. She received 5m…

emergency medicineintensive caremonitoringsystemdroperidol
VIChospital2024-07-30

Finding into death of Jason Nicholas Hosie

48y · Male·Aspiration pneumonia in a man with Angelman syndrome

Jason Hosie, a 48-year-old man with Angelman syndrome and profound intellectual disability, died from aspiration pneumonia following a lung infection. He was residing in specialist disability accommodation. In December 2…

neurologyrespiratory medicine
VIChospital2024-07-29

Finding into death of Shane Anthony Pappas

54y · Male·quetiapine toxicity in a man with ischaemic heart disease

Shane Pappas, a 54-year-old man with ischaemic heart disease, died from quetiapine toxicity after deliberately overdosing on multiple medications on 29 June 2021. He had experienced a recent relationship breakdown and pr…

psychiatryemergency medicinediagnosticcommunicationquetiapine
TAShospital2024-07-25

Coroner's Finding: Briffa, Gennette Anne

73y · Female·sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopi…

A 73-year-old woman died from sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass surgery. She had complex medical history with multiple post-operative complicatio…

bariatric surgerygeneral surgerydiagnosticdelayapixaban
VIChospital2024-07-25

Finding into death of Nathan Ruan Roy Greenwood

18y · Male·Sodium nitrite toxicity

Nathan Greenwood, an 18-year-old with a history of anxiety and depression managed in primary care, died from sodium nitrite toxicity after intentionally consuming 30 grams of the substance. He had been under care at his …

general practicepsychiatrysystemdelaysodium nitrite
VIChospital2024-07-23

Finding into death of Laurence Maxwell Attwood

68y · Male·Ischaemic infarction of the right cerebral hemisphere and cerebellum due to thro…

A 68-year-old man died from ischaemic stroke (basilar artery and right posterior cerebral artery thrombosis) seven days after being struck by a motor vehicle while attempting to cross Warrigal Road, Hughesdale. The colli…

trauma surgeryneurosurgerysystem
VICcommunity2024-07-18

Finding into death of Frankie Skye Foulkes

0y · Female·Complications of spinal muscular atrophy

Frankie Skye Foulkes, a four-month-old diagnosed with spinal muscular atrophy type 1, died from complications of SMA while positioned in a standard car seat during a car journey. She had recently commenced nusinersen tre…

neurologyoccupational therapysystemnusinersen
TAShospital2024-07-11

Coroner's Finding: Fletcher, Errol Adrian

74y · Male·traumatic closed head injuries

Errol Adrian Fletcher, a 74-year-old man, died from traumatic closed head injuries sustained when struck by a vehicle while crossing a service station driveway in Huonville on 28 November 2022. He was transported to Roya…

trauma surgeryintensive care
WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat f…

psychiatryintensive carecommunicationsystempaliperidone
TAShospital2024-06-21

Coroner's Finding: de-identified BP

16y · Male·transection of the liver and laceration of the inferior vena cava sustained in a…

A 16-year-old male died from transection of the liver and inferior vena cava laceration sustained in a quad bike accident. He was riding a single-rider ATV with a pillion passenger when he entered a left-hand corner too …

trauma surgeryemergency medicine
QLDhospital2024-06-21

Non-inquest findings into the death of Mr K

81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…

An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 retention require explicit ident…

respiratory medicineemergency medicinemedicationcommunicationdiazepam
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