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VIChospital2011-09-19

Finding into death of Stephen Johnson

47y · Male·Multiple organ failure due to Aeromonas Sobria sepsis in a man with cirrhosis

Stephen Johnson, a 47-year-old teacher, died from sepsis caused by Aeromonas Sobria bacteria acquired through a cut hand exposure to contaminated farm water. He presented to hospital with non-specific symptoms and elevat…

emergency medicineinfectious diseasesdelay
VIChospital2011-09-05

Finding into death of Sheryl Yvonne Martell

49y · Female·aspiration pneumonia complicating cerebral palsy

Ms Sheryl Yvonne Martell, a 49-year-old woman with cerebral palsy and severe intellectual disability residing in a group home, died from aspiration pneumonia. She was admitted to hospital on 21 June 2010 after vomiting a…

general practiceemergency medicinebenzylpenicillin
VIChospital2011-07-13

Finding into death of Nuray Yurekturk

39y · Female·Sepsis and renal failure secondary to a perinephric abscess

A 39-year-old woman with quadriplegia, cerebral palsy, and epilepsy residing in supported accommodation developed a perinephric abscess detected when staff noticed a raised area on her lower back. She presented to hospit…

urologyemergency medicine
VIChospital2011-07-13

Finding into death of Mary Welsh

44y · Female·pneumonia complicating epilepsy in a woman with microcephaly

Mary Welsh, aged 44, with intellectual impairment, microcephaly, severe kyphoscoliosis and epilepsy was admitted with upper respiratory symptoms and treated for presumed pneumonia. She developed an allergic reaction to R…

emergency medicineneurologyrulide
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
VIChospital2011-07-08

Finding into death of Jan Szustak

84y · Male·Aspiration pneumonia associated with vascular and Alzheimer dementia

An 84-year-old man with vascular and Alzheimer dementia died from aspiration pneumonia at Latrobe Regional Hospital. He had been under an Inpatient Treatment Order, but this critical status was not communicated to the re…

geriatric medicinerespiratory medicinecommunicationsystem
NSW2011-07-01

Coroner's Finding: Michael Peter Magro

40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…

Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…

correctional healthgeneral practicediagnosticcommunicationmethadone
NSW2010-12-14

Maryannroberts281 05 finding14december2010

73y · Female·Bacterial endocarditis organism arising from a staphylococcal infection that ent…

Mary Roberts, aged 73, received a 5-year custodial sentence in September 2004. She had complex medical needs: dementia from previous strokes, diabetes requiring insulin monitoring, and Warfarin use. Justice Health provid…

correctional healthgeriatric medicinediagnosticcommunicationwarfarin
VICcommunity2010-12-09

Finding into death of DONNA LAVINIA FAURE

39y · Female·neurological disorder of unknown cause and right axillary abscess

Donna Lavinia Faure, aged 39, lived in a Department of Human Services group home with a lifelong neurological disability requiring full-time care. In June 2009, she developed an axillary abscess with bacterial infection …

general practiceemergency medicine
SAhospital2010-12-06

Coroner's Finding: GEORGE Irene Thelma

84y · Female·septicaemia secondary to septic arthritis of the left knee

An 84-year-old woman presented to hospital with acute left knee swelling and pain. Initial assessment at Ashford Hospital ED reasonably excluded septic arthritis based on borderline blood tests and absence of fever, thou…

emergency medicinegeneral medicinediagnosticcommunicationmorphine
VICaged care2010-09-08

Finding into death of Nina Solyk

87y · Female·Sepsis

An 87-year-old woman with dementia, heart failure, and cerebrovascular disease died of sepsis on an aged psychiatry unit. She was admitted under mental health legislation following behavioural deterioration. On 11 March,…

geriatric medicineinfectious diseases
SA2010-06-07

Coroner's Finding: THOMPSON Kym Joseph Paul

45y · Male·sepsis with infective endocarditis, right lobar pneumonia (with abscess formatio…

A 45-year-old man with severe disability (wheelchair-bound following burn injury), borderline personality disorder, and chronic medical conditions including ischaemic heart disease, hypertension, diabetes, and recent pne…

emergency medicineinfectious diseasesmorphine
SAhospital2010-06-03

Coroner's Finding: PROMNITZ Aileen Dawn

79y · Female·Sepsis due to urinary tract infection with Group B streptococci

A 79-year-old nursing home resident died of sepsis from urinary tract infection with Group B streptococci after waiting 6 hours in the Emergency Department without being seen by a doctor. She arrived at 8pm with normal v…

emergency medicineinfectious diseasesdelaysystem
VIChospital2010-06-01

Finding into death of Eileen Frances Wilson

52y · Female·Aspiration pneumonia complicating end-stage dementia

Eileen Wilson, a 52-year-old woman with Down's syndrome and Alzheimer's dementia, died from aspiration pneumonia after 27 days of hospitalisation. She was transferred to hospital in early July 2009 after DHS staff noted …

geriatric medicineinfectious diseasescefriaxone
VIChospital2010-03-24

Finding into death of Adam Michael Francis Fabre

19y · Male·acute bacterial meningitis with secondary cerebritis (meningococcus)

Adam Fabre, a 19-year-old with fever, severe headache, neck pain, muscle pain (10/10), vomiting, tachycardia and blanching rash, presented to Casey Hospital ED at 3:45am on 14 July 2006. Despite expressing clear concern …

emergency medicineinfectious diseasesdiagnosticcommunicationparacetamol/codeine
VIChospital2010-03-22

Finding into death of Magdalena Schauer

36y · Female·Acute brain injury due to intracerebral haemorrhage secondary to sepsis

A 36-year-old woman with intravenous heroin use history presented with depressed consciousness and purpuric rash. Paramedics appropriately administered empiric antibiotics for suspected meningococcal sepsis. Hospital inv…

emergency medicineintensive careheroin
VIChospital2010-03-15

Finding into death of Deborah Margaret Ricklefs

29y · Female·Invasive aspergillosis

A 29-year-old registered nurse with systemic lupus erythematosus (SLE) died from invasive aspergillosis. Dr G. prescribed lamotrigine 100 mg daily (double the recommended initial dose of 50 mg) on first consultation with…

addiction medicinegeneral practicemedicationdiagnosticlamotrigine
NThome2010-01-19

Inquest into the death of Deborah Leanne Melville

12y · Female·acute septicaemia resulting from osteomyelitis of the left femur

A 12-year-old Aboriginal girl died from septicaemia caused by untreated osteomyelitis of the left femur. Three weeks after a sports injury, despite evidence of severe and deteriorating illness including inability to walk…

orthopaedic surgeryinfectious diseasesdiagnosticsystem
QLDhospital2009-12-08

Congoo, Sharon Faye

40y · Female·Bacterial septicaemia from an unknown organism

Sharon Faye Congoo died from overwhelming bacterial septicaemia of unknown origin at age 40. She presented to Mareeba Hospital (a small rural facility) on three occasions with non-specific viral-like symptoms and leg pai…

emergency medicineintensive caresystemcommunication
QLDhospital2009-11-20

Johnston, Margaret Allan

82y · Female·Complications from hypoglycaemic brain damage and cerebral vascular accident

Margaret Allan Johnston, 82-year-old admitted for UTI and confusion, was found comatose on 4 September 2006 with severe hypoglycaemia (glucose 0.8 mmol/L) despite being non-diabetic. Blood tests revealed high insulin and…

anaesthesiaendocrinologymedicationsysteminsulin

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