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SAhospital2024-06-19

Coroner's Finding: Ferns, Patricia Dorothy

79y · Female·cardiogenic shock following repair of fractured right femur on a background of a…

Mrs Patricia Ferns, aged 79, died from cardiogenic shock following femur fracture repair, complicated by underlying aortic valve stenosis, atherosclerotic disease and hypertension. She fell at home and was admitted with …

cardiologyorthopaedic surgery
VIChospital2024-06-14

Finding into death of Joshua Paul Coates

49y · Male·Acute myocardial infarction complicating prosthetic valve thrombosis in a man wi…

Joshua Paul Coates, aged 49, died from acute myocardial infarction complicating prosthetic valve thrombosis following mechanical aortic valve replacement. Post-mortem examination revealed a large blood clot obstructing h…

cardiothoracic surgerycardiologycommunicationsystemwarfarin
WAprison2024-06-12

Inquest into the Death of Alf Deon EADES

46y · Male·head injury complicated by bronchopneumonia, with palliation

A 46-year-old remand prisoner died from traumatic brain injury sustained during a severe prison assault. Critical failures in responding to cell call alarms preceded the attack. Prison officers answered multiple distress…

correctional healthneurosurgerycommunicationsystem
SAhospital2024-05-22

Coroner's Finding: Kolega, Sime

54y · Male·multi-organ failure and sepsis complicating fulminant pneumonia with empyema (op…

A 54-year-old man died from sepsis and multi-organ failure secondary to fulminant pneumonia with empyema. He presented to his GP on 1 April 2021 with concerning signs including bilateral oedema, fever, and respiratory sy…

general practiceemergency medicinedelaysystemflixotide
SAhospital2024-05-16

Coroner's Finding: Fisher, Lynne Patricia

60y · Female·sepsis due to community acquired pneumonia

Lynne Patricia Fisher, 60, presented to Mount Barker Hospital ED on 26 September 2018 with bilateral community-acquired pneumonia and was discharged after 6.5 hours despite clinical deterioration. She collapsed at home w…

emergency medicinegeneral practicediagnosticdelayamoxicillin/clavulanate
QLD2024-05-13

HARVEY, Thompson

33y · Male·Neck compression (hanging)

Thompson James Harvey, aged 33, died by hanging in his cell at Capricornia Correctional Centre on 13 November 2017, four days after remand for serious offences including attempted murder. He had a recent suicide attempt …

psychiatrypsychologycommunicationdiagnosticmorphine
VIChospital2024-05-10

Finding into death of Peter Fiorakis

72y · Male·Complications of small bowel obstruction in a man with multiple medical co-morbi…

Peter Fiorakis, a 72-year-old man with intellectual disability, schizophrenia, recurrent DVT, cardiomegaly, COPD, ischaemic heart disease and hiatus hernia, presented to Austin Hospital with nausea, vomiting and decrease…

general medicinesurgery
NSWhospital2024-05-10

Inquest into the death of Finlay Browne

16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…

Finlay Browne, a 16-year-old with Down syndrome, presented to Bathurst Base Hospital on 30 September 2016 with acute abdominal pain and vomiting. Despite clear clinical signs—including a lactate of 7.2 mmol/L (grossly ab…

emergency medicinesurgerydiagnosticcommunication
NSWcommunity2024-05-03

Inquest into the death of Keith Titmuss

20y · Male·exertional heat stroke

A 20-year-old professional rugby league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest aerobic fitness of hi…

sports medicineemergency medicinesystemdelaymidazolam
QLDhospital2024-04-22

Non-inquest findings into the death of Lenore

48y · Female·Hypoxic ischaemic encephalopathy due to pulmonary thromboembolism due to deep ve…

A 48-year-old woman with morbid obesity and smoking history presented to a rural hospital with severe hip and leg pain. Over five days across two hospitals, no venous thromboembolism (VTE) risk assessment was performed d…

emergency medicineorthopaedic surgerydiagnosticsystemoxycodone
VIChospital2024-04-19

Finding into death of Andrew Peter De Julia

61y · Male·Ischaemic heart disease in the setting of aspiration pneumonia in a man with Pra…

Andrew Peter De Julia, a 61-year-old man with Prader-Willi syndrome, complex medical history including severe ischaemic heart disease, and multiple comorbidities, died of ischaemic heart disease complicated by aspiration…

general medicineintensive carenoradrenaline
TAShospital2024-04-16

Coroner's Finding: Smith, Lance Royal

62y · Male·Advanced atherosclerotic and hypertensive coronary vascular disease

Lance Royal Smith, aged 62, died from advanced atherosclerotic coronary vascular disease following a motorcycle crash on 4 November 2023. He was riding an unregistered, mechanically defective Harley Davidson at high spee…

emergency medicinetrauma surgerycannabis
VIChospital2024-04-08

Finding into death of Benjamin Suggate

40y · Male·Complications of Influenza A infection in a man with cerebral palsy and congenit…

Benjamin Suggate, a 40-year-old man with cerebral palsy, congenital brain malformation, quadriplegia and intellectual disability living in specialist disability accommodation, died from complications of Influenza A infec…

respiratory medicineinfectious diseasesantiviral medication
TAShospital2024-03-27

Coroner's Finding: Leary, Kane

17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…

Kane Mathew Leary, 17, died from a stroke (left middle cerebral artery infarction) following a motorbike collision. The critical clinical lesson involves a missed diagnosis of left internal carotid artery dissection on i…

emergency medicineneurosurgerydiagnosticcommunicationmorphine
TAS2024-03-26

Coroner's Finding: Knight, Daniel Thomas

43y · Male·Crush injuries (chest and abdominal injuries and chest compression) sustained in…

Daniel Thomas Knight, aged 43, died from crush injuries sustained while attempting to clear a blockage in a wastepaper compactor (model TCU 660) at a printing business. The compactor had never functioned correctly due to…

occupational and environmental healthforensic medicinesystemproceduralantiepileptic drugs
VIChospital2024-03-13

Finding into death of K M

18y · Male·Drug toxicity (3,4-methylenedioxy-N-methylamphetamine (MDMA), methylone)

An 18-year-old male died from drug toxicity (MDMA and methylone) following ingestion at a music festival. He collapsed 4 hours after consuming three MDMA capsules over one hour, suffered cardiac arrest at the festival me…

emergency medicineintensive careMDMA
TAShospital2024-03-07

Coroner's Finding: Menz, Michelle Joy

58y · Female·pulmonary thromboembolism due to deep venous thrombosis following pelvic trauma

Michelle Joy Menz, aged 58, died from pulmonary thromboembolism secondary to deep vein thrombosis following pelvic trauma sustained in a motor vehicle crash on 17 January 2023. She was admitted to Royal Hobart Hospital w…

trauma surgeryemergency medicine
QLDhospital2024-03-07

KLUMPER Joshua William

17y · Male·Hanging

17-year-old Joshua Klumper died by hanging following cannabis withdrawal and workplace stress. He had a complex mental health history with ASD diagnosis (lacking robust diagnostic support), multiple suicide attempts, and…

psychiatryemergency medicinecommunicationsystemcannabis
QLD2024-03-07

BROWN Samuel Timothy

20y · Male·Head injury from motor vehicle collision

Samuel Timothy Brown, age 20, died from severe head injury sustained in a motor vehicle collision on 25 November 2012. He was found lying on the Gold Coast Highway with a blood alcohol level of 0.241% (approximately 4 ti…

emergency medicineintensive carealcohol
NSWmental health2024-03-06

Inquest into the death of RA

64y · Female·hypoxic ischemic encephalopathy caused by neck compression and hanging

A 64-year-old woman with a history of childhood trauma, anxiety and depression was admitted to an acute mental health unit (Kurrajong Unit) under involuntary care following a suicide attempt. Within 24 hours, she accesse…

psychiatryemergency medicinesystemproceduralmirtazapine
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