Coronial
SAhospital2016-08-03

Coroner's Finding: LAMBROPOULOS Andrea

34y · Male·hypoxic-ischaemic encephalopathy following laparoscopic bariatric surgery with i…

Andrea Lambropoulos, a 34-year-old man with morbid obesity, sleep apnoea, and ischaemic heart disease, died following sleeve gastrectomy. He was admitted to HDU rather than ICU po…

bariatric surgeryanaesthesiacommunicationdelaymorphine
VIC2023-08-04

Finding into death of Katrina Jane Cervasio

43y · Female·Complications of obesity including cardiomegaly

Katrina Jane Cervasio, a 43-year-old woman with intellectual disability, obesity, sleep apnoea, and cerebral palsy, died from complications of obesity including cardiomegaly while living in a disabilit…

respiratory medicinegeneral practicesystemdelayparacetamol
VIChospital2025-06-25

Finding into death of Melanie Louise Gregory

39y · Female·aspiration pneumonia in the setting of general anaesthesia and colonoscopy for i…

A 39-year-old woman with cerebral palsy, dysphagia, and sleep apnoea died from aspiration pneumonia following a colonoscopy performed under sedation for investigation of recta…

gastroenterologyanaesthesia
QLD2009-04-24

Broe, Stephen James

45y · Male·Fulminant cardio-pulmonary decompression sickness incidental to deep water techn…

…multiple medical conditions including obesity, hypertension, Conn's syndrome, and severe obstructive sleep apnoea, died from fulminant cardio-pulmonary decompression sickness following a technical deep dive to 50 metres.…

diving medicinediagnosticcommunicationmidamor
SAmental health2008-07-17

Coroner's Finding: TARNOWSKI Marek Tomasz

33y · Male·Respiratory failure due to mixed drug toxicity (amitriptyline, oxycodone, morphi…

A 33-year-old man with chronic back pain, depression, morbid obesity and sleep apnoea died in psychiatric custody from respiratory failure due to mixed drug toxicity and probable aspiration. H…

psychiatryemergency medicinesystemamitriptyline
WAmental health2019-05-22

Inquest into the Death of Pamela Edith ASHLEY

64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…

A 64-year-old woman with bipolar disorder, severe obstructive sleep apnoea, obesity and diabetes presented with acute psychotic relapse following stress and sleep deprivation. Initi…

psychiatryemergency medicinecommunicationsystemchlorpromazine
VICmental health2024-04-19

Finding into death of Allison Naomi Eagle

44y · Female·Unascertained, presumed sudden cardiac death

…nd bipolar affective disorder died unexpectedly in a psychiatric inpatient unit. She had obstructive sleep apnoea and was on multiple antipsychotic medications. On the night before her planned discharge, she received PRN…

psychiatryrespiratory medicinezuclopenthixol deconoate
WAhospital2019-08-02

Inquest into the Death of Timothy James CHANDLER

52y · Male·multiple organ failure and pulmonary thromboemboli complicating generalised seps…

…care presented with severe cellulitis, sepsis, and previously undiagnosed heart failure secondary to sleep apnoea. He lacked capacity to consent to treatment due to a psychotic illness and was appropriately placed on an …

emergency medicinegeneral medicine
NSWmental health2026-02-19

Inquest into the death of Jacob McDonald

51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…

…ntary forensic psychiatric patient with treatment-resistant schizoaffective disorder and obstructive sleep apnoea. While expert evidence confirmed excellent psychiatric and cardiac care, clinicians should note: (1) postm…

psychiatrycardiologycommunicationsystemclozapine
VIChospital2025-07-15

Finding into death of Linda Snadden

62y · Female·Aspiration pneumonia in the setting of refractory focal status epilepticus

…-old woman with cognitive decline, brain tumour history, and multiple comorbidities including severe sleep apnoea and pulmonary hypertension, died from aspiration pneumonia during refractory focal status epilepticus. She…

neurologyneurosurgeryanti-seizure medications
WAmental health2019-05-22

Inquest into the Death of Christopher John DEBNAM

40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…

Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric d…

psychiatryrespiratory medicinediagnosticcommunicationhaloperidol
SA2026-03-13

Coroner's Finding: Holding, Matthew Benjamin

44y · Male·unascertained

…ng from a dental issue. Medical staff recommended hospital assessment and CPAP therapy for suspected sleep apnoea; he refused both despite being informed of death risk. He fell in his cell on 1 January and was found unre…

psychiatrycorrectional healtholanzapine
ACThome2022-05-19

Inquest into the Death of PAMELA VANCE

83y · Female·pneumonia with generalised atherosclerosis as a significant contributor

…atherosclerosis as a significant contributor. She had multiple comorbidities including COPD, asthma, sleep apnoea and heart disease, complicated by recent falls and repeated pneumonia requiring intubation. After four mon…

respiratory medicinegeneral practice
VICcommunity2020-05-22

Finding into death of Christina Maree Chamberlain

60y · Female·Multiple injuries sustained in a motor vehicle incident (driver)

…pable of causing drowsiness. She had significant comorbidities including hypertension, cardiomegaly, sleep apnoea, and chronic back pain. While the coroner could not definitively establish whether medications or a medica…

emergency medicineforensic medicineoxycodone
WAhome2021-06-22

Inquest into the Death of Child AM (Name Subject to Suppression Order)

3y · Female·bronchopneumonia in an infant with obstructive sleep apnoea

A 3-year-old Aboriginal girl died from bronchopneumonia complicated by severe obstructive sleep apnoea. She had rapid-onset childhood obesity (36 kg at death; normal weight 14-16 kg) with multiple cardiopulmon…

paediatricsrespiratory medicinecommunicationsystem
SAhospital2016-02-08

Coroner's Finding: FIDGE Patricia Ann

67y · Female·choking and ischaemic heart disease

…isease. She was admitted with delirium, hypernatremia, and multiple comorbidities including COPD and sleep apnoea. While eating breakfast on day 3 of admission, she aspirated food material that lodged in her right main b…

emergency medicinepsychiatryrisperidone
NSW2023-07-21

Inquest into the death of Reuben Button

34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…

…d no access to dietitian, Aboriginal Health Worker, or timely specialist investigations (cardiac and sleep apnoea despite referrals). Buvidal was commenced with only 1 day on Suboxone (guidelines suggest 7 days minimum),…

psychiatrygeneral practicediagnosticsystembuvidal
SA2022-03-30

Coroner's Finding: Hohol, Peter

68y · Male·decompensated heart failure with pulmonary hypertensive crisis complicated by pn…

…inical issues identified were: (1) unavailability of his CPAP machine despite documented obstructive sleep apnoea requiring it in the community; (2) mobility barriers limiting access to the prison health centre. However,…

cardiologygeneral medicine
VIChospital2025-01-08

Finding into death of Mark Ruth

50y · Male·Sepsis of unknown organism in respiratory

…ld NDIS participant with cerebral palsy, intellectual disability, chronic dysphagia, and obstructive sleep apnoea, died from sepsis of unknown respiratory organism. He had experienced declining health with six hospitalis…

emergency medicinerespiratory medicinesodium valproate
NSWcustody2022-07-21

Inquest into the death of Richard Navarro

43y · Male·Hypoxic Ischaemic Encephalopathy due to out of hospital cardiac arrest, secondar…

Richard Navarro, a 43-year-old man with severe obstructive sleep apnoea (OSA), morbid obesity, hypertension, and recurrent pneumonia, died of hypoxic ischaemic encephalopathy fol…

respiratory medicinecardiologysystem

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