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TAShospital2023-10-11

Coroner's Finding: Jones, Emily Margaret Rose

82y · Female·traumatic closed head injury (subdural haematoma) resulting from a fall from sta…

Mrs Emily Jones, 82, died from subdural haematoma following an unwitnessed fall at Royal Hobart Hospital on 15 November 2021. She was admitted five days after discharge from Hobart Private Hospital where she was treated …

cardiologyemergency medicinemedicationcommunicationmetoprolol
VIChospital2023-10-06

Finding into death of G A

86y · Female·Bradycardic arrest secondary to relative hypoperfusion while undergoing surgery …

An 86-year-old woman underwent elective surgery to excise a probable squamous cell carcinoma from her left hand with split-thickness skin grafting under local anaesthesia with intravenous sedation. She suffered an unexpe…

dermatologyplastic and reconstructive surgerymedicationpropofol
TAScommunity2023-10-04

Coroner's Finding: East, Robert William

78y · Male·subdural haematoma

Robert William East, 78, died from a subdural haematoma sustained when his electric wheelchair became uncontrollable on a gravel path in Glenmore Creek Reserve. He had consumed approximately five beers at the Granada Tav…

emergency medicineneurosurgerysystem
QLD2023-10-03

Findings of the inquest into the death of GLT

46y · Male·Methylamphetamine toxicity and coronary atherosclerosis

A 46-year-old man died in police custody following a domestic violence order breach arrest in Rockhampton, Queensland. The death resulted from a combination of methylamphetamine toxicity, significant coronary artery dise…

emergency medicineintensive carediagnosticdelaymethamphetamine
VICcommunity2023-09-18

Finding into death of Meeram Bano

2y · Female·Hypoxic ischaemic encephalopathy in the setting of immersion

Meeram Bano, aged 2 years, died from hypoxic ischaemic encephalopathy following immersion in a pond at Footscray Park on 27 December 2021. She was declared dead on 30 December 2021. While under adult supervision at a fam…

intensive careemergency medicinesystemdelaymidazolam
TAShospital2023-09-12

Coroner's Finding: Harris, Peter Blackwell

75y · Male·pneumonia and head injury from fall

Peter Harris, aged 75, was admitted with behavioural disturbance and hyponatraemia (low serum sodium of 124 mmol/L). Initial clinical assessment did not identify falls risk. After 4 days, he fell backwards suddenly while…

general medicinegeriatric medicinediagnosticquetiapine
VIC2023-09-07

Finding into death of Betty Torrance Sloan

86y · Female·Bronchopneumonia complicating chest injuries sustained in a motor vehicle collis…

An 86-year-old woman died from bronchopneumonia complicating chest injuries sustained in a motor vehicle collision on 17 June 2019. A stolen vehicle being driven recklessly by an unlicensed driver under the influence of …

intensive careemergency medicinecommunicationsystemmethamphetamine
SAhospital2023-08-30

Coroner's Finding: Fergusson, Logan Scott

0y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease

Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Chil…

cardiologypaediatricsdelaydiagnosticheparin
VIChospital2023-08-29

Finding into death of Edward Michael Schutz

80y · Male·Complications of vertebral artery and right carotid artery vascular injuries (op…

An 80-year-old retired surgeon died from complications of vertebral artery and right carotid artery vascular injuries and cervical spine injuries sustained in a body surfing incident at Sandy Gully Beach. He was struck b…

emergency medicineneurosurgeryacetone
VICcommunity2023-08-25

Finding into death of Mr P

26y · Male·Brain death post mixed drug toxicity including MDMA and cocaine

Mr P, aged 26, attended the Karnival Music Festival in Melbourne on 13 March 2022 and consumed cocaine and high-dose MDMA (Blue Punisher pill). He experienced seizures, hyperthermia (42.2°C), and bradycardia, and was tre…

emergency medicineintensive careMDMA
VIChospital2023-08-25

Finding into death of Mr P

26y · Male·Brain death post mixed drug toxicity including MDMA and cocaine

Mr P, a 26-year-old man, died from brain death following mixed drug toxicity from MDMA and cocaine consumed at a music festival. He presented with seizures, hyperthermia (42.2°C), and rigidity at the festival medical ten…

emergency medicineintensive careMDMA
NSWhospital2023-08-22

Inquest into the death of AN

0y · Female·Methylamphetamine toxicity

A newborn baby died 8 hours after birth from methylamphetamine toxicity acquired in utero. The mother unknowingly consumed methylamphetamine in the days before labour, likely by drinking from a contaminated bottle at a r…

neonatologypaediatricsmethamphetamine
NSWhome2023-08-15

Inquest into the death of LA

5y · Female·Hypoxic-ischaemic Encephalopathy due to methadone toxicity

LA, a five-year-old girl, died from hypoxic-ischaemic encephalopathy due to methadone toxicity on 22 January 2017. She ingested methadone at her grandfather's home while staying overnight; the grandfather was enrolled in…

paediatricsintensive caredelaycommunicationmethadone
VIChospital2023-08-14

Finding into death of Md Fakrul Alam Sozon

33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …

A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Phy…

gastroenterologyintensive careproceduraldiagnostic
NSWhospital2023-08-11

Inquest into the death of Andrew Stubbs

32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome

Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…

general practicepsychiatrydiagnosticmedicationlithium
TAShospital2023-08-02

Coroner's Finding: Nalder Michael Graeme

63y · Male·pulmonary thrombo-emboli following coronary artery bypass grafting

Michael Nalder, 63, died from pulmonary thromboembolism on postoperative day 9 following elective coronary artery bypass grafting for severe coronary artery disease. He had multiple significant comorbidities including Ty…

cardiothoracic surgeryintensive careunfractionated heparin
VIChospital2023-08-01

Finding into death of Michele Valentino

81y · Male·Head injury sustained in a fall

Michele Valentino, 81, died from a head injury sustained in a fall on 20 December 2019, with death occurring on 24 December 2019. A CT angiogram at 3:45pm showed worsening intraventricular haemorrhage (IVH) that was not …

emergency medicineradiologydiagnosticcommunicationaspirin
VIChospital2023-07-31

Finding into death of Michael Stankic

29y · Male·Pulmonary thromboembolism secondary to deep venous thrombosis

A 29-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis (DVT) following a suicide attempt by hanging. He was admitted to ICU and appropriately commenced on prophylactic enoxaparin 40mg dai…

intensive carepsychiatrysystemdelayenoxaparin
NSWhospital2023-07-21

Inquest into the death of Ziad Hamawy

51y · Male·complications of opiate toxicity; cardiac and respiratory arrest following drug …

Ziad Hamawy, a 51-year-old man with chronic schizophrenia and polysubstance use disorder, died from opiate toxicity after cardiac arrest following his discharge from Concord Hospital's mental health unit on 18 March 2019…

psychiatryemergency medicinediagnosticcommunicationheroin
VIC2023-07-19

Finding into death of Angela Cuthbert

59y · Female·complications of abscesses following dental extraction, in a woman with cerebral…

Angela Cuthbert, a 59-year-old woman with severe cerebral palsy and dysphagia, died from complications of abscesses following extraction of all 14 teeth under general anaesthetic. Surgery occurred 20 June 2022; she devel…

oral and maxillofacial surgerydentistrycommunicationsystem
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