Coronial
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SAhospital2011-07-08

Coroner's Finding: BAIS Jamie Stuart

39y · Male·pneumococcal meningitis with severe cerebral oedema due to pneumococcal mastoidi…

Jamie Stuart Bais, a 39-year-old man with acute otitis media and sinusitis, was admitted to Flinders Medical Centre for what was thought to be a straightforward ENT infection. Over 15 days, he developed pneumococcal meni…

ENT surgeryinfectious diseasesdiagnosticcommunicationceftriaxone
SAhospital2003-03-04

Coroner's Finding: VASSALLO Virginia

59y · Female·multiple cerebral infarction due to infective endocarditis

…emic toxicity combined with her known valvular disease history—should have prompted hospital admission and sepsis workup with blood cultures and broad-spectrum antibiotics. The patient re-presented the next day more unwe…

emergency medicinecardiologydiagnosticdelayparacetamol/codeine
WAhospital2012-05-18

Inquest into the Death of Allan

16y · Male·Pneumonia complicating influenza A (H1N1) infection with secondary Staphylococcu…

Andrew Allan, a 16-year-old student, died from pneumonia complicating influenza A (H1N1) infection with secondary Staphylococcus aureus septicaemia. He presented to Northam Regional Hospital Emergency Department on 16 Se…

emergency medicinegeneral practicediagnosticcommunicationmethylphenidate
NSWhospital2023-03-09

Inquest into the death of William Edmunds

79y · Male·complications of peritonitis

A 79-year-old man with multiple comorbidities presented with a perforated bowel requiring emergency Hartmann's procedure. The operating surgeon, Dr L.-Ming Schmidt, made a catastrophic surgical error by exteriorising the…

general surgeryintensive careproceduraldiagnosticmorphine
QLDhospital2021-01-27

Brown, Tara Matekino - Non-inquest findings

24y · Female·Head injury from repeated blunt force trauma

A 24-year-old woman was fatally assaulted by her intimate partner after a period of escalating domestic and family violence. The perpetrator had a documented history of violent DFV across multiple relationships, with pri…

emergency medicineintensive carediagnosticcommunication
NSWhospital2024-01-29

Inquest into the death of Sean Montgomery

70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia

70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…

cardiothoracic surgerygeneral surgerydiagnosticcommunicationmorphine
VIChospital2014-04-17

Finding into death of Gail Fergusson

65y · Female·Liver failure secondary to paracetamol toxicity

A 65-year-old retired nurse died from paracetamol toxicity and liver failure after taking excessive paracetamol tablets for pain relief following a fractured arm. She presented to hospital on Saturday with a fracture. Cr…

emergency medicineendocrinologycommunicationsystemparacetamol
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
SAcommunity2012-11-15

Coroner's Finding: Edgar Lauren Michelle

28y · Female·Multi-organ failure due to Clostridium perfringens myonecrosis complicating lipo…

Lauren Edgar, a 28-year-old woman, died of multi-organ failure from Clostridium perfringens myonecrosis (gas gangrene) following a liposuction procedure performed by Dr K. on 5 March 2008. She presented to hospital on 8 …

plastic and reconstructive surgerygeneral practicediagnosticcommunicationpanadol/paracetamol
VIChospital2018-02-28

Finding into death of Samuel Carl Johansen

36y · Male·Multi-organ failure complicating injecting drug use

…d and was found 29 hours later, developed multi-organ failure from complications of injecting drug use and sepsis, and died 6 November 2012. While the death resulted from unintended consequences of drug injection rather …

psychiatryintensive carecommunicationdelayheroin
QLDhospital2007-11-23

Scholz, Karl David

31y · Male·Upper airway obstruction due to pharyngeal abscess caused by dental abscess, whi…

Karl Scholz, 31-year-old male, died from upper airway obstruction due to pharyngeal abscess originating from untreated dental infection. He presented with severe facial cellulitis and abscess following dental procedures …

intensive careanaesthesiadiagnosticcommunicationamoxicillin
NSWhospital2019-06-14

Inquest into the death of Melissa King

33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…

Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraem…

intensive careendocrinologydiagnosticcommunicationglycoprep
NSWhospital2014-09-26

Inquest into the death of AA

10y · Male·hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…

AA, a 10-year-old boy with morbid obesity and severe obstructive sleep apnoea, died from hypoxic brain injury after a cardiorespiratory arrest. He had been admitted to hospital in May 2008 with these diagnoses and was pr…

respiratory medicineendocrinologycommunicationsystemmethadone
QLDhospital2017-06-22

Mead, Gwendoline

73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…

…nterventions, she became fluid-overloaded with declining renal function. She deteriorated on day 6 with urosepsis and acute kidney injury requiring ICU admission. After initial improvement, she was discharged back to the…

colorectal surgerygeneral surgerydiagnosticdelay5-fluorouracil
QLDhospital2023-06-30

Booth, Yvette and Sandy, Adele and George, Shakaya (“RHD Doomadgee Cluster”)

Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…

This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…

cardiologyemergency medicinecommunicationsystempenicillin

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