Coronial
NTaged care2021-01-07

Inquest into the death of Robert Curtis

61y · Male·end stage renal failure, in the context of type 2 diabetes mellitus and chronic …

…s revealed severe hypotension and ascites requiring drainage. His clinical condition deteriorated despite dialysis, and discussions focused on palliative care. After a family meeting, he was granted compassionate leave t…

nephrologypalliative carefentanyl
WAhospital2019-05-31

Inquest into the Death of Aurelio Monterlegre CRUZ

80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…

…hopneumonia complicating terminal palliative care while a sentenced prisoner. He had consistently refused dialysis from early 2016 onwards, a decision ultimately supported by his family and considered reasonable by his n…

nephrologypalliative carecommunicationdelayinsulin
VIChospital2019-07-30

Finding into death of Allison Judith Allan

43y · Female·Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxic…

…, failed to escalate deterioration to senior staff, and over-relied on initial VPIC guidance; WBH delayed dialysis initiation by >24 hours despite clear indicators (cerebral oedema, cardiovascular instability, metabolic …

emergency medicineintensive carediagnosticcommunicationsodium valproate
WAhospital2019-08-02

Inquest into the Death of Timothy James CHANDLER

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

… on an involuntary treatment order. Despite aggressive multispecialty management including ICU admission, dialysis, and extensive supportive care, he died from multiple organ failure and pulmonary emboli complicating sep…

emergency medicinegeneral medicine
SAhospital2013-09-03

Coroner's Finding: MUMFORD Michael John

41y · Male·multi-organ failure due to severe lactic acidosis due to metformin toxicity

…empt. He presented to the ED conscious and coherent, reporting the overdose. He was admitted to ICU where dialysis was commenced. Despite appropriate management including intubation and ventilation, severe lactic acidosi…

intensive careemergency medicinemetformin
SAhospital2009-09-18

Coroner's Finding: VONDERWALL Frederick Albert

66y · Male·hepatorenal failure and biliary sepsis complicating common bile duct obstruction

…cer. He underwent ERCP with stent insertion and required ICU support including mechanical ventilation and dialysis. After extubation on 18 April, he explicitly declined further aggressive treatment and life support. Care…

general surgeryintensive care
SAhospital2020-01-10

Coroner's Finding: FIORETTI Louisa Jill Josephine

19y · Female·2,4-dinitrophenol toxicity

…der in place. Despite expert multidisciplinary management including sedation, intubation, ECMO, attempted dialysis, charcoal administration, and dantrolene use, she deteriorated rapidly with uncontrollable hyperthermia a…

toxicologyemergency medicine2,4-dinitrophenol
SAhospital2000-05-31

Coroner's Finding: DELLATORRE Natale

54y · Male·respiratory failure and acute renal failure due to rhabdomyolysis following trau…

…sis became established, his death became almost inevitable despite comprehensive ICU management including dialysis, intubation, and tracheostomy. Communication breakdown occurred between ICU staff and family regarding wi…

emergency medicinepsychiatrydiagnosticadrenaline
VIChome2024-08-19

Finding into death of Siya Yogin Patel

0y · Female·hyperviscosity-related brain injury secondary to hypernatraemic dehydration

Siya Patel, a 23-day-old neonate, died from hyperviscosity-related brain injury secondary to severe dehydration caused by insufficient breastfeeding. Her family were recent emigrants without Medicare eligibility, creatin…

neonatologygeneral practicediagnosticcommunication
ACThospital2014-03-03

Findings Into The Death Of Sukanya Thurairajah

56y · Female·hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and f…

…comorbidities including obesity, diabetes, coronary disease, and metastatic breast cancer, underwent haemodialysis at Canberra Hospital on 29 July 2011. She had an adverse reaction characterised by vomiting, breathlessne…

anaesthesiaintensive careproceduralcommunicationhydrocortisone
TASmental health2018-10-19

Coroner's Finding: Bowden, Frederick Rocky

59y · Male·aspiration pneumonia and end stage renal failure due to obstructive uropathy and…

…rch 2015 with severe renal failure. Palliative care was decided given his psychiatric condition precluded dialysis. He was transferred to Roy Fagan Centre on 10 April 2015 and died two days later. The coroner found his m…

psychiatrynephrologyclozapine
TASaged care2025-01-14

Coroner's Finding: Rickard-Simms, Adrienne Rosemary

75y · Female·postoperative delirium/exacerbation of community acquired pneumonia following le…

A 75-year-old woman with chronic kidney disease, anemia, and significant mobility impairment fell in her aged care facility despite documented high falls risk and appropriate preventive measures. She sustained a neck of …

geriatric medicineorthopaedic surgery
VIChospital2021-02-25

Finding into death of Laurence Joseph Kermond

65y · Male·Complications of end stage renal failure in a man with multiple co-morbidities

Mr Kermond, a 65-year-old man with intellectual disability, visual and hearing impairment living in a group home, was admitted to Lyndoch Living for respite care on 25 July 2019. He had end-stage renal failure and multip…

general practicenephrology
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
SAhospital2020-07-16

Coroner's Finding: GRAEFE Phillip Brian

62y · Male·Multi-organ failure due to paraquat ingestion

A 62-year-old man with diabetes, renal failure, and hypertension died from multi-organ failure following intentional ingestion of approximately 100-150ml of paraquat. He had recently assumed sole responsibility for the f…

toxicologyemergency medicineparaquat
SAhospital2015-08-13

Coroner's Finding: DICKERSON Alexander Charles

79y · Male·multi-organ failure due to voluntary starvation on a background of severe depres…

A 79-year-old man died from multi-organ failure secondary to voluntary starvation in the context of severe depression following his wife's death. He was admitted after police found him malnourished following 30 days of i…

psychiatrygeneral medicine
VIChospital2025-07-08

Finding into death of KD

48y · Female·Combined effects of cardiac hypertrophy, chronic obstructive pulmonary disease a…

KD, a 48-year-old woman with chronic schizo-affective disorder, end-stage renal failure, COPD, cardiac hypertrophy and obesity, died from combined natural causes while under assessment order in psychiatric care. She pres…

psychiatryintensive careolanzapine
QLD2019-06-20

Mallie, William Michael

58y · Male·Atherosclerotic cardiovascular disease

…liam Mallie, a 58-year-old Torres Strait Islander man, died of sudden cardiac arrest while receiving haemodialysis in prison. He had end-stage renal disease, long-standing poorly controlled type 2 diabetes since 1985, hy…

nephrologycardiology
SAaged care2020-12-18

Coroner's Finding: DUTSCHKE Brenton Leslie

72y · Male·ischaemic heart disease on a background of end-stage renal failure and frontotem…

…se. He had complex medical needs including diabetes, hypertension, atrial fibrillation, and required haemodialysis. His dementia caused executive dysfunction, impulsivity, and aggressive behaviour that prevented mainstre…

psychiatrynephrology
SAhospital2022-03-29

Coroner's Finding: Foster, Clive Anthony

76y · Male·end-stage renal failure

…ess, complicated by pneumonia, stroke, and cardiac dysfunction. He was assessed and deemed unsuitable for dialysis. The coroner found that adequate medical care was provided both in prison and hospital, with appropriate …

general medicinenephrology

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