Coronial
WAhospital2016-09-28

Inquest into the Death of Donald Richard BROADRIBB

79y · Male·Bronchopneumonia and acute bronchiolitis

Donald Broadribb, 79, died of bronchopneumonia and acute bronchiolitis after presenting to York Hospital on 12 October 2012 with vomiting, cough, and abdominal pain. He was discharged after nurses focused on treating con…

emergency medicinegeneral practicediagnosticcommunicationhyoscine butylbromide
WAprison- 20 March 2014

Inquest into the Death of Anthony Nigel AXTELL

38y · Male·Heart failure in a man with dilated cardiomyopathy and focal severe coronary art…

Anthony Axtell, a 38-year-old man with severe dilated cardiomyopathy from amphetamine use, died of heart failure while in prison custody. Initially treated successfully in 2002 with recovery to normal cardiac function by…

cardiologycardiothoracic surgerymedicationsystemamphetamine
SAcommunity2022-04-22

Coroner's Finding: Bentley, John James

80y · Male·Dehydration and the effects of heat with contributing Alzheimer's dementia

An 80-year-old man with advanced Alzheimer's dementia disappeared from a respite care facility on a day of extreme heat (39°C) and died from dehydration and heat exposure. Key failures included: (1) relocation of the day…

geriatric medicineemergency medicinediagnosticsystem
WAhospital2015-08-12

Inquest into the Death of Helen Christine MacFARLAINE

52y · Female·intracerebral haemorrhage in a lady with underlying cerebrovascular disease and …

A 52-year-old woman underwent right carotid endarterectomy for high-grade stenosis. Post-operatively she developed escalating blood pressure readings (160–220 mmHg), headaches, nausea, agitation, and abnormal behaviour o…

neurosurgeryintensive carecommunicationsystemaspirin
NSWPodcast2020-12-18

GORE Bernard - Findings

Male·The available evidence does not allow for any finding to be made as to the cause…

Bernard Gore, a man with Alzheimer's dementia, entered a fire stairwell at Westfield Bondi Junction shopping center in Sydney on 6 January 2017 and became trapped. He likely died within 24-48 hours from cardiac complicat…

systemcommunication
NSW2016-11-04

Inquest into the death of Phillip Hughes

25y · Male·traumatic basal subarachnoid haemorrhage due to vertebral artery dissection

Phillip Hughes, a 25-year-old professional cricketer, died from traumatic basal subarachnoid haemorrhage caused by vertebral artery dissection after being struck on the neck by a cricket ball during a Sheffield Shield ma…

emergency medicineneurosurgerycommunicationsystem
ACThospital2025-04-09

Inquest Into The Death Of Peter Hanisch

69y · Male·thoracic aortic aneurysm with dissection

…n the CT images but 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 b…

radiologyemergency medicinediagnosticsystem
SAaged care2008-02-07

Coroner's Finding: WELLS Gladys Ruth

71y · Female·undetermined

71-year-old woman found dead in unusual position at Brighton aged care facility. Her body was positioned with head resting against bed pole, with marks on neck and bruising observed by carers. The death was certified as …

geriatric medicinegeneral practicediagnosticsystem
VIChome2016-10-07

Finding into death of Milica (Mary) Minchev

48y · Female·Combined drug toxicity involving oxycodone, benzodiazepines (diazepam, nordiazep…

A 48-year-old woman with epilepsy, depression, anxiety and documented drug dependence died from combined toxicity of oxycodone, benzodiazepines, amitriptyline and other drugs. Over 12 months pre-death, she obtained medic…

general practicepsychiatrydiagnosticmedicationoxycodone
QLDhospital2024-11-08

Non-inquest findings into the death of SD

61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed

A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…

haematologypathologydiagnosticcommunicationprednisolone
SAhospital2018-10-10

Coroner's Finding: ATKINS Stephen Robert

53y · Male·fentanyl and oxycodone toxicity

Stephen Robert Atkins, 53, died from fentanyl and oxycodone toxicity after admission to Flinders Medical Centre for investigation of Horner's syndrome and radiculopathy. Over three days, escalating opioid doses were pres…

neurologyemergency medicinediagnosticmedicationfentanyl
SAcommunity2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes: hanging (three cases); exposure in context of organic brain dam…

Four Anangu (Aboriginal) young men died between May 2003 and March 2004 on the Anangu Pitjantjatjara Lands in South Australia. Three deaths were by hanging (ages 19, 25, 27); one by exposure (age 35). Deaths were linked …

psychiatryemergency medicinesystemdelaypetrol
NSWhospital2022-12-21

Inquest into death of Andrea LESTER

49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…

Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfu…

neurosurgeryintensive carediagnosticcommunicationtramadol

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