Coronial
ACThospital2025-04-09

Inquest Into The Death Of Peter Hanisch

69y · Male·thoracic aortic aneurysm with dissection

…ented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angiogram was performed but the radiologist, Dr CD, failed to identify the aortic dissection, instead reporting on…

radiologyemergency medicinediagnosticsystem
VIChospital2026-04-28

Finding into death of Ronald William Beaumont

74y · Male·Acute myocardial infarction complicated by multiple organ failure

Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…

cardiologyorthopaedic surgerymedicationcommunicationaspirin
VIChospital2024-03-07

Finding into death of Ms AC

73y · Female·Metastatic oesophageal cancer

Ms AC, a 73-year-old woman with longstanding physical disabilities, died from metastatic oesophageal cancer. She presented with progressive swallowing difficulties, weight loss, and elevated inflammatory markers from Dec…

general practicegastroenterology
SAhospital2015-08-13

Coroner's Finding: HILL John George Charles

71y · Male·acute pyelonephritis with contributing ischaemic heart disease

A 71-year-old male prisoner died from acute pyelonephritis with contributing ischaemic heart disease at Flinders Medical Centre. He had advanced metastatic gastric cancer diagnosed in February 2011 after presenting with …

colorectal surgerygeneral surgery
NSW2020-09-04

Inquest into the death of Stephen Pitty

70y · Male·Complications of Ischaemic cardiomyopathy and Chronic Obstructive Pulmonary Dise…

Stephen Pitty, aged 70, died from complications of ischaemic cardiomyopathy and chronic obstructive pulmonary disease whilst in custody at Long Bay Correctional Centre. He had significant cardiac history including seven …

cardiologyrespiratory medicine
SAhospital2022-04-14

Coroner's Finding: Esposito, Pasquale

76y · Male·combined effects of acute myocardial infarction and urosepsis

Pasquale Esposito, age 76, died in custody at Lyell McEwin Hospital from combined acute myocardial infarction and urosepsis. He had extensive cardiac history including prior MI, CABG, COPD, and recent stent placement. On…

cardiologyinfectious diseasesantibiotics
SAhospital2024-06-19

Coroner's Finding: Ferns, Patricia Dorothy

79y · Female·cardiogenic shock following repair of fractured right femur on a background of a…

…developed acute pulmonary oedema requiring ICU admission. Cardiology identified myocardial ischaemia; an angiogram was discussed but her condition deteriorated rapidly with cardiogenic shock and multi-organ failure. The…

cardiologyorthopaedic surgery
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
VIChospitalPodcast2021-12-10

Finding into death of Peta Hickey

43y · Female·Multisystem organ failure and hypoxic/ischaemic encephalopathy following anaphyl…

…ta Hickey, a 43-year-old company executive with no cardiac history, died from anaphylaxis to CT coronary angiogram contrast after her employer commissioned an inappropriate screening program. The referral lacked clinica…

radiologyemergency medicinediagnosticmedicationomnipaque 350 contrast dye
VIChospital2019-08-07

Finding into death of Leon Edward Balshaw

55y · Male·Bronchopneumonia in a man with a healing myocardial infarction

Leon Edward Balshaw, aged 55, died from bronchopneumonia complicating a healing myocardial infarction while in police custody. He was arrested on 25 January 2018 following a domestic dispute and taken to Bairnsdale Regio…

emergency medicineintensive care
VIChospital2025-04-30

Finding into death of Margaret Ann Day

66y · Female·Ischaemic brainstem stroke

Margaret Ann Day, a 66-year-old Specialist Disability Accommodation resident with undifferentiated hereditary ataxia, intellectual disability, and dysphagia, presented to the Emergency Department on 26 November 2024 with…

neurologyemergency medicinelevetiracetam
SAhome2016-08-04

Coroner's Finding: KALME Dearne Lee

51y · Female·undetermined - either citalopram toxicity or ischaemic heart disease

A 51-year-old woman died at home on 15 October 2013 while on home detention bail. She had been hospitalized in July 2013 following suspected drug overdose/withdrawal, during which she developed secondary kidney and heart…

psychiatrycardiologycitalopram
SA2021-11-25

Coroner's Finding: Clark, Murray Eric

81y · Male·valvular heart disease with cardiac amyloidosis

Murray Eric Clark, 81-year-old prisoner with extensive cardiac history including aortic stenosis, sick sinus syndrome with pacemaker, and recent TAVI procedure, collapsed and died in prison infirmary on 20 September 2019…

cardiologyemergency medicineanticoagulants
NSWhospital2020-02-12

Inquest into the death of Francis Sawle

82y · Male·Acute myocardial infarction caused by ischaemic heart disease

Francis Sawle, an 82-year-old man in custody, died of acute myocardial infarction due to ischaemic heart disease while an inpatient at Prince of Wales Hospital. He had significant comorbidities including severe triple ve…

cardiologypalliative careperindopril
SAhospital2025-11-14

Coroner's Finding: Wallace, Peter John

67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …

Peter John Wallace, aged 67, died in custody at Lyell McEwin Hospital from hypoxic respiratory failure complicating pneumonia, pulmonary embolism, and advanced hepatocellular carcinoma. He had been imprisoned at Yatala L…

hepatologyoncologyenoxaparin
TAShospital2023-05-05

Coroner's Finding: Pedler, Anne Helen

71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis

…g made, no anticoagulation or thrombolytic therapy was initiated. Instead, staff waited for CT pulmonary angiogram, which was delayed due to absent pathology results, unfamiliar ordering systems, and lack of radiographe…

emergency medicinecardiologydiagnosticdelaycannabis oil
VIChospital2022-03-09

Finding into death of Daniel McQuilken

68y · Male·Lung cancer

Daniel McQuilken, a 68-year-old man in immigration detention, died from metastatic lung cancer. His lung cancer diagnosis was made while detained, likely related to his significant smoking history and prior asbestos and …

oncologyrespiratory medicinechemotherapy agents
VIChospital2025-02-12

Finding into death of Alexander Cameron

40y · Male·Aspiration pneumonia

Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia f…

intensive caregeneral surgeryclozapine
VIChospital2021-05-31

Finding into death of Ms Jane

13y · Female·hypoxic ischaemic encephalopathy secondary to gamma hydroxybutyrate toxicity

Jane, aged 13, died from hypoxic ischaemic encephalopathy secondary to gamma hydroxybutyrate (GHB) toxicity following accidental overdose. She ingested an estimated 6-9mls of GHB in early June 2017, having used the drug …

emergency medicineintensive caregamma hydroxybutyrate
VIChospital2014-10-01

Finding into death of Raymond John O_Brien

71y · Male·acute myocardial infarction due to coronary artery disease

Raymond O'Brien, a 71-year-old forensic patient with a history of ischaemic heart disease, hypertension, and dyslipidaemia, was admitted to hospital with chest pain in August 2013. Initial diagnosis of non-ST elevation a…

cardiologypsychiatryaspirin

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