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VIC2024-02-12

Finding into death of Maahi Tukapua

73y · Male·Acute on chronic renal failure and multi-factorial encephalopathy in a man with …

A 73-year-old man with significant comorbidities (cirrhosis, dilated cardiomyopathy, chronic kidney disease) died in prison from acute-on-chronic renal failure, hepatic encephalopathy, and multiorgan failure. He was init…

cardiologynephrologymorphine
SAhospital2023-12-22

Coroner's Finding: FORREST, John Michael

68y · Male·Multi-organ failure due to gram-negative sepsis on a background of recent myocar…

A 68-year-old male prisoner with multiple comorbidities (diabetes, end-stage renal failure, COPD, morbid obesity) presented with acute myocardial infarction and underwent coronary artery bypass grafting. Post-operatively…

cardiothoracic surgerycardiologyglyceryl trinitrate
WAhospital2023-08-30

Inquest into the Death of Kevin George HOWLETT

83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)

An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …

vascular surgerygeneral medicinediagnosticcommunication
NSWhospital2023-08-11

Inquest into the death of Andrew Stubbs

32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome

Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…

general practicepsychiatrydiagnosticmedicationlithium
NSWcommunity2023-08-01

Inquest into the death of Peter Gretton

64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…

Peter Gretton, a 64-year-old man imprisoned at Junee Correctional Centre, died from metformin toxicity complicated by acute renal impairment and severe lactic acidosis. His renal function deteriorated in the three to fou…

emergency medicinecardiologydiagnosticcommunicationmetformin
VIChospital2023-07-24

Finding into death of Rona Jean Mccully

83y · Female·Acute on chronic renal failure secondary to infectious exacerbation of chronic o…

An 83-year-old woman with chronic obstructive pulmonary disease and chronic renal failure died from acute-on-chronic renal failure complicated by infectious exacerbation of COPD. She presented to hospital on 13 October 2…

general practicerespiratory medicinemolnupiravir
QLDhospital2023-07-05

Conlon, Edgar

75y · Male·End-stage renal disease, with hypertension, ischaemic heart disease, and diabete…

Edgar Hugh Sandow, a 75-year-old First Nations man, died from end-stage renal disease while incarcerated at Princess Alexandra Hospital Secure Unit. He had multiple comorbidities including heart failure, diabetes, hypert…

nephrologycardiologyaspirin
NSWhospital2023-03-15

Inquest into the death of Matthew Smith

47y · Male·Follicular lymphoma with transformation to acute lymphoblastic leukaemia and the…

Matthew Geoffrey Smith, a 47-year-old man imprisoned for sexual offences, died in the ICU of Prince of Wales Hospital on 5 May 2022 from follicular lymphoma that had transformed to acute lymphoblastic leukaemia with comp…

oncologyhaematology
SAhospital2022-12-22

Coroner's Finding: Shore Wayne John

55y · Male·right intracerebral haemorrhage and left middle cerebral artery cerebrovascular …

Wayne Shore, 55, died from right intracerebral haemorrhage and left middle cerebral artery stroke complicating infective endocarditis, end-stage renal failure, and multiple myeloma. He was subject to a Level 1 Inpatient …

neurologynephrologyanticoagulant therapy
VICaged care2022-10-19

Finding into death of Paul Henry Green

83y · Male·Unascertained (natural causes)

Paul Henry Green, 83-year-old man with intellectual disability and multiple chronic conditions including renal failure on dialysis, was found unresponsive in his bed at a residential care facility. He had been isolating …

geriatric medicinenephrologymetoprolol
VIChospital2022-10-18

Finding into death of Kenneth Ernest O'Brien

74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair

A 74-year-old man with significant cardiac history (atrial fibrillation, dilated cardiomyopathy, pacemaker) underwent elective umbilical hernia repair. Intraoperatively, unexpected ascites was discovered and partially dr…

general surgeryanaesthesiadiagnosticcommunicationapixaban
NSWhospital2022-08-17

Inquest into the death of Robert Bischard

75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…

Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…

orthopaedic surgerycardiologydiagnosticsystemfurosemide
TAShome2022-07-15

Coroner's Finding: Summers, Nicholas John

41y · Male·heart failure related to exsanguination due to traumatic rupture of an arteriove…

Nicholas Summers, a 41-year-old kidney transplant recipient, died from traumatic rupture of an arteriovenous fistula with massive hemorrhage on 16 February 2016. He had returned to Tasmania under nephrologist Dr Mathew's…

nephrologyvascular surgerysystemdelay
WAhospital2022-06-08

Inquest into the Death of Salvatore Giovanni OTRANTO

68y · Male·Complications following myocardial infarction and its treatment in a man with mu…

Salvatore Otranto, a 68-year-old prisoner with multiple severe comorbidities including ischaemic heart disease, diabetes, COPD, and chronic kidney disease, died from complications of myocardial infarction and its treatme…

cardiologyintensive careproceduralenoxaparin
SAhospital2022-03-29

Coroner's Finding: Foster, Clive Anthony

76y · Male·end-stage renal failure

A 76-year-old man died of end-stage renal failure while imprisoned. He had pre-existing hypertension, diabetes, and stage 3 chronic kidney disease. During his final year in custody, he experienced acute kidney injury sup…

general medicinenephrology
WA2022-02-04

Inquest into the Death of Robert William ROMAN

55y · Male·Subdural haematoma in a man with diabetes mellitus and chronic kidney disease (r…

A 55-year-old Aboriginal man with end-stage renal disease, diabetes, ischaemic heart disease and COPD died from a spontaneous subdural haematoma while undergoing haemodialysis in prison custody. He presented with headach…

nephrologyemergency medicinesystemcommunicationaspirin
NSW2021-11-30

Inquest into the death of Elias MELHEM

49y · Male·atherosclerotic and hypertensive cardiovascular disease, with type 2 diabetes me…

Elias Melhem, aged 49, died in custody from atherosclerotic and hypertensive cardiovascular disease with contributing type 2 diabetes. On 8 December 2019, he experienced chest pain at work but reported feeling better aft…

cardiologynephrologycommunicationinsulin
TAShospital2021-11-29

Coroner's Finding: Bennett, Anthony George

77y · Male·shock due to bowel ischaemia following massive blood loss due to bleeding of the…

Anthony George Bennett, a 77-year-old man with significant comorbidities including ischaemic heart disease, atrial fibrillation, peripheral vascular disease, and end-stage kidney disease, died from shock due to bowel isc…

vascular surgerycardiology
NSW2021-11-18

Inquest into the death of Conway PERRIE

75y · Male·Complications of chronic renal disease on a background of hypertension and type …

Conway Perrie, a 75-year-old man in lawful custody at Long Bay Correctional Complex, died from complications of chronic renal disease (stage 4) with hypertension and type 2 diabetes mellitus. He had been reviewed at Prin…

nephrologyemergency medicine
NSWhospital2021-10-05

Inquest into the death of Timothy MOFFATT

72y · Male·metastatic prostate carcinoma

Timothy Moffatt, a 72-year-old man in prison custody, died from metastatic prostate cancer. He had declined cancer treatment from 2014-2018 but agreed to chemotherapy after metastatic disease was identified. He also had …

oncologynephrologychemotherapy

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