Coronial
TASaged care2015-11-12

Coroner's Finding: Henri, Paul Lucien

78y · Male·Cerebral infarction and hypoxic brain damage due to the combined effects of isch…

…oxicity was clinically suspected, no blood toxicology was retained to confirm. The coroner highlighted that CPAP does not protect against opioid-induced respiratory depression, and recommended pain management specialist …

general practiceneurologymedicationdiagnosticmorphine
NSWhospital2018-12-17

Inquest into the death of Jarrod Wright

42y · Male·Cardiac arrest following hypoxic ischaemic encephalopathy, likely due to E.coli …

Jarrod Wright, a 42-year-old man admitted with cellulitis, developed sepsis-related acute respiratory distress syndrome (ARDS) requiring ICU care with non-invasive ventilation. Critical failures occurred in managing his …

intensive careinfectious diseasescommunicationsystemmeropenem
NSWhospital2014-09-26

Inquest into the death of AA

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

…diorespiratory arrest. He had been admitted to hospital in May 2008 with these diagnoses and was prescribed CPAP treatment and advised to lose weight. Despite being told his condition was life-threatening and at "medical…

respiratory medicineendocrinologycommunicationsystemmethadone
QLDhospital2021-02-24

Petzler, Dennis Michael

59y · Male·Carcinomatosis due to adenocarcinoma of the pancreas

Dennis Petzler, a 59-year-old prisoner, died from carcinomatosis due to adenocarcinoma of the pancreas with extensive metastatic spread. He presented with abdominal pain and nausea in June 2018, initially managed as gast…

oncologygeneral medicinedexamethasone
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
WAhospital2015-07-02

Inquest into the Death of John MAJINSKI

55y · Male·Complications of fibrosing alveolitis

John Majinski, a 55-year-old prisoner with severe fibrosing alveolitis, pulmonary hypertension, diabetes, and recurrent infections, died from complications of his lung disease while incarcerated. He received intensive me…

respiratory medicinegeneral medicinemirtazapine
SAhospital2013-02-08

Coroner's Finding: FENSOM Angela Catherine and TAANKINK Johaanes Andrew

Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …

Two deaths from H1N1 influenza in 2009. Ms Fensom (41) died from myocarditis complicating swine flu after inadequate recognition and management of persistent hypotension at Millicent Hospital. Her condition required esca…

emergency medicinegeneral practicediagnosticcommunicationoseltamivir
VIChospital2026-01-08

Finding into death of Malakai Cross-De Jesus

0y · Male·Complications following forceps delivery

…k was high (APGAR <7 at 5 min, prolonged labour, multiple pulls) yet scalp observations were delayed due to CPAP bonnet obscuring assessment; (3) early recognition of SGH would have allowed earlier tailored resuscitation…

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
WAhome2025-06-24

Inquest into the Death of Leighton Michael WOOD

44y · Male·bronchopneumonia in the setting of combined drug effect

Leighton Wood, 44, died from bronchopneumonia in the setting of combined drug effect. He had schizoaffective disorder, anti-social personality disorder, and chronic polysubstance use disorder (alcohol, methylamphetamine,…

psychiatrypathologyzuclopenthixol decanoate
WAhospital2021-01-04

Inquest into the Death of Baby JDU

0y · Male·Scimitar syndrome

An 11-week-old term infant (Baby JDU) died from Scimitar syndrome, a rare congenital heart and lung disorder with bilateral complications including pulmonary hypoplasia, venous obstruction, and severe pulmonary hypertens…

cardiologyneonatologysildenafil
VIChospital2025-04-10

Finding into death of Hau Bui Nguyen

46y · Male·Aspiration pneumonia complicating epistaxis in the setting of prolonged nasal pr…

Hau Bui Nguyen, a 46-year-old man with severe acquired brain injury, dysphagia, and recurrent aspiration pneumonia, died from aspiration pneumonia complicating epistaxis following prolonged nasal prong oxygen therapy. Du…

general medicineemergency medicineamoxicillin
VIChospital2022-09-30

Finding into death of Baby RMI

0y · Male·Perinatal hypoxia

An 8-day-old neonate died of perinatal hypoxia on 14 December 2019, 8 days after emergency caesarean section. The infant presented with seizures, hypotonia, and severe encephalopathy. Autopsy revealed severe global cereb…

obstetricsneonatologycommunicationsystemintrathecal morphine
WAhospital2019-09-23

Inquest into the Death of Dylan James RILEY

16y · Male·pulmonary embolism secondary to nephrotic syndrome

Dylan Riley, a 16-year-old with steroid-responsive minimal change nephrotic syndrome, died from a massive pulmonary embolism (PE) on 1 August 2015. He presented to Rockingham Hospital with dyspnoea, hypoxia, tachycardia …

nephrologyintensive caredelayenoxaparin
VIChospital2020-05-21

Finding into death of Baby S

Female·Sepsis in the setting of a lotus birth

A premature female neonate born at 36+5 weeks via emergency caesarean section developed sepsis and died at 2 days of age. She had been delivered with lotus birth (cord left attached to placenta) and vaginal seeding (mate…

obstetricspaediatricscommunicationsystembenzylpenicillin
VIChospital2013-05-09

Finding into death of Tyler Reading-Adams

0y · Male·Intrapartum hypoxia due to true knot in umbilical cord with cord wrapped three t…

Tyler Reading-Adams died at 95 minutes old from intrapartum hypoxia caused by a true knot in his umbilical cord wrapped three times around his neck. The mother presented at 40 weeks 6 days gestation with spontaneous rupt…

obstetricsmidwiferynitrous oxide
WAmental health2024-07-19

Inquest into the Death of Phillip Benjamin VELTMAN

49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…

Phillip Veltman, 49, died of unascertained cause (likely cardiac arrhythmia with terminal aspiration) while an involuntary psychiatric patient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on…

psychiatryemergency medicinecommunicationsystemketamine
QLDcommunity2009-04-21

Kay, Brendan Scott

0y · Male·Sudden Infant Death Syndrome (SIDS) against a background of sub-glottic stenosis…

Brendan Scott Kay, a 104-day-old ex-premature infant with sub-glottic stenosis from prolonged neonatal intubation, died suddenly in his parents' car during transfer home from Brisbane to Tully. The stenosis had been inve…

neonatologyENT surgerycommunicationsystemdexamethasone
QLDhospital2017-06-22

PS - Non-inquest findings

68y · Female·Coronary heart disease

A 68-year-old woman with diabetes, hypertension, hypercholesterolaemia, COPD and chronic renal failure presented with chest pain and dyspnoea. She was admitted with suspected congestive cardiac failure; troponins were no…

cardiologyemergency medicinediagnosticcommunicationfurosemide

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