Coronial
VIChospital2019-11-11

Finding into death of Finn Moser

1y · Male·Head injury in the setting of labour

Finn Moser was a one-day-old neonate who died from head injury sustained during labour and delivery at the Royal Women's Hospital. He was born to a mother with dichorionic diamniotic twins, induced at 36 weeks due to pre…

obstetricsneonatologydiagnosticcommunicationprostaglandin gel
QLDcommunity2016-04-20

Newport, Glenn Richard

38y · Male·cardiac arrest precipitated by dilutional hyponatraemia

A 38-year-old construction worker died from dilutional hyponatraemia after working in extreme heat (>40°C) on a concrete formwork project in rural Queensland. He developed symptoms of heat injury at the worksite and was …

occupational and environmental healthparamedicinediagnosticcommunication
SA2018-11-01

Coroner's Finding: CASTILLO-RIFFO Jorge Alberto

54y · Male·hypoxic-ischaemic encephalopathy resulting from neck compression due to entrapme…

Jorge Castillo-Riffo, a 54-year-old construction worker, died from hypoxic-ischaemic encephalopathy resulting from neck compression. While working on a scissor lift to patch post-tensioning pockets on a concrete slab edg…

occupational and environmental healthforensic medicinesystemprocedural
WAhospital2008-07-28

Inquest into the Death of kidner

41y · Male·Head Injury in a Man with Acute Alcohol Intoxication; basal skull fracture with …

Ronald Gregory Kidner, 41, died from a basal skull fracture and severe head trauma on 25 October 2004, four days after falling at a recreation club while acutely intoxicated. He presented to Nickol Bay Hospital with sign…

emergency medicinegeneral medicinediagnosticcommunicationalcohol
VIChospital2020-07-16

Finding into death of Lydia Maxfield

85y · Female·Multisystem failure complicating ischaemic heart disease and ischaemic bowel in …

Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnorm…

orthopaedic surgeryanaesthesiacommunicationsystemondansetron
VIChospital2020-07-14

Finding into death of Gerard Guy Vaz

61y · Male·Undetermined

Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuc…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
VICaged care2019-02-21

Finding into death of Kathleen Schleibs

88y · Female·Sepsis complicated by multiple organ failure in a woman with comorbidities in th…

An 88-year-old woman died from sepsis with multiple organ failure following shoulder surgery. She developed an undiagnosed urinary tract infection after placement of an indwelling catheter. Critical failures included: in…

orthopaedic surgerygeriatric medicinediagnosticcommunicationfentanyl
QLDhospital2010-10-29

Spence, Samantha Rose

12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…

Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI of her spine. A paediatric…

orthopaedic surgeryneurologydiagnosticcommunicationmorphine
SAhospital2014-11-14

Coroner's Finding: KEY George Darcy

0y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…

George Darcy Key, an 8-day-old neonate, died from perinatal hypoxic ischaemic encephalopathy following labour complicated by excessive syntocinon-induced contractions and delayed obstetric intervention. The infant was de…

obstetricsanaesthesiadiagnosticcommunicationoxytocin
QLDhospital2025-03-31

Inquest into the death of Jamie Brian Campbell

43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…

A 43-year-old man with methamphetamine toxicity was restrained by police and given two doses of droperidol by paramedics who failed to recognize he was critically unwell. The first dose was clinically indicated, but the …

emergency medicinetoxicologydiagnosticmedicationmethamphetamine
WA2016-09-27

Inquest into the Death of Baby Z

0y · Male·unascertained

Baby Z, born to a serving prisoner on 3 March 2011, died suddenly on 3 April 2011 at Bandyup Women's Prison at one month of age. Despite extensive forensic investigation, the cause of death remained unascertained, though…

obstetricsneonatologycommunicationdelaymethadone
QLDhospital2018-07-09

AD - Non-inquest findings

75y · Male·Multi-organ failure secondary to cardiogenic shock and anterior myocardial infar…

A 75-year-old man presented to a tertiary hospital ED with acute anterior STEMI but diagnosis was delayed by approximately 10 hours. The first hospital ECG at 6:47am showed diagnostic ST elevation but was not recognised …

emergency medicinecardiologydiagnosticcommunicationmorphine
VIChospital2025-10-17

Finding into death of Rachel Frances Piskun

42y · Female·Pneumonia, underlying severe cerebral palsy

Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…

emergency medicinegeneral medicinediagnosticmedicationmorphine
WAhospital2017-08-23

Inquest into the Death of Marjorie Joy JARICK

54y · Female·Opioid toxicity (predominantly fentanyl)

54-year-old woman with diabetes, obesity, and multiple opioid allergies underwent groin surgery at a private hospital. Anaesthetist Dr Y. prescribed a 75mcg/hr fentanyl patch post-operatively for chronic pain management …

anaesthesiasurgerymedicationcommunicationfentanyl
QLDhospital2024-11-20

Non-inquest findings into the death of Mr W

82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis

An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …

general medicinegeriatric medicinediagnosticcommunicationendone 2.5mg
NThospital2011-09-09

Inquest into the death of Linda Nha Tran

34y · Female·Catastrophic post-partum haemorrhage following caesarean delivery, secondary to …

A 34-year-old Vietnamese woman died from catastrophic postpartum haemorrhage following an elective caesarean delivery. Placenta accreta was discovered intraoperatively and managed with blood transfusion, uterotonic agent…

obstetricsanaesthesiamedicationcommunicationoxytocin
WAhospital2023-04-17

Inquest into the Death of Edward Ivan AFRICH

64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …

Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…

respiratory medicinecardiologycommunicationsystemthiamine
QLDhospital2008-11-28

McVey, Oliver Steven

67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent clo…

Oliver Steven McVey, a premature twin born at 31 weeks gestation weighing 1036g, died from complications of endotracheal tube re-insertion at 67 days of age. Following successful surgical ligation of a patent ductus arte…

neonatologycardiothoracic surgeryproceduralcommunication
SAhospital2014-02-14

Coroner's Finding: RYAN John William and WALTON Patricia Dawn

Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…

Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…

anaesthesiaorthopaedic surgerydiagnosticcommunicationmorphine
ACThome2017-03-23

AN INQUEST INTO THE DEATH OF PAP

55y · Male·Septicaemia due to hydronephrosis and infection

A 55-year-old man with complex medical and social problems died of septicaemia from renal infection. He had a history of cardiac disease requiring anticoagulation, alcohol dependence, depression, and chronic hoarding beh…

cardiologypsychiatrysystemcommunicationwarfarin

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