Coronial
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SAhospital2003-03-28

Coroner's Finding: BUTLER Irene

72y · Female·haemorrhage from penetrating duodenal ulcer

A 72-year-old woman collapsed at home and was admitted with black bowel motions (melaena) suggestive of gastrointestinal bleeding. This crucial history was documented by the ED doctor but not properly acted upon by the a…

emergency medicinegeneral medicinediagnosticcommunicationaspirin
SAhospital2002-03-28

Coroner's Finding: PETROCCIA Assunta

26y · Female·cardiorespiratory arrest due to massive gastric dilatation with gastric rupture

Assunta Petroccia, a 26-year-old woman, died from cardiorespiratory arrest due to massive gastric dilatation with rupture following a bulimic episode. She presented to hospital with severe abdominal pain and was incorrec…

surgeryemergency medicinediagnosticcommunicationmorphine
SAhospital2001-09-07

Coroner's Finding: SANDS Celia Laurel

82y · Female·peritonitis due to a perforated viscus (proximal jejunum) resulting from motor v…

An 82-year-old woman suffered a motor vehicle accident causing blunt abdominal trauma. Despite initial clinical assessment appearing adequate, a perforated jejunum with developing peritonitis was not diagnosed until earl…

general surgeryemergency medicinediagnosticdelay
SAhospital2001-05-04

Coroner's Finding: ROACH Dawn Ruth

45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…

A 45-year-old woman died from multi-organ failure following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (1.5 cm) was contained and re…

colorectal surgerygeneral surgeryproceduralcommunication
SAhospital2000-04-12

Coroner's Finding: RUSSELL Brian Edward

80y · Male·bronchopneumonia complicated by morphine toxicity

An 80-year-old man with terminal liver disease died from bronchopneumonia complicated by morphine toxicity following a medication administration error. A Graseby infusion pump was incorrectly set at 99mm/hour instead of …

palliative caregastroenterologymedicationproceduralmorphine
WAhospital

Inquest into the Death of Robin David MACARTNEY

62y · Male·bronchopneumonia in a man receiving terminal palliative care for metastatic carc…

Robin David Macartney, a 62-year-old prisoner serving a life sentence for murder, died from bronchopneumonia secondary to metastatic colon cancer. He was diagnosed with sigmoid colon cancer in December 2006 but refused s…

oncologygeneral surgery
VIChospital

Finding into death of Jocelyn Riddiford

52y · Female·Unascertained (natural causes)

Jocelyn Riddiford, a 52-year-old woman with intellectual disability and autism residing in supported accommodation, died from unascertained natural causes. Over 18 months prior to death, she experienced progressive decli…

general practicegastroenterologymorphine
VIChospital

Finding into death of Mr C

55y · Male·Ascending cholangitis due to choledocholithiasis

A 55-year-old man with Down syndrome died from ascending cholangitis due to choledocholithiasis following recurrent biliary sepsis. He had multiple comorbidities including Alzheimer's disease, depression, and cardiac dys…

intensive caregeneral medicineantibiotics

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