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WAprison2021-09-06

Inquest into the Death of Marshall Ruben EDGILL

38y · Male·combined effects of acute-on-chronic respiratory disease and cardiomegaly

Marshall Ruben Edgill, a 38-year-old Indigenous man, died in custody from acute-on-chronic respiratory disease and cardiomegaly. He had longstanding obstructive sleep apnoea (OSA), obesity, asthma, and hypertension. Crit…

respiratory medicinecardiologydiagnosticdelay
WAhome2021-08-26

Inquest into the Death of Baby E (Name Subject to Suppression Order)

0y · Male·Complications of VATER syndrome and sacrococcygeal teratoma

Baby E was a 7-month-old neonate with VATER syndrome and sacrococcygeal teratoma who died from complications of these conditions. He was born prematurely at 30 weeks, requiring intubation and ventilation, and remained in…

neonatologynephrology
WAhospital2021-08-06

Inquest into the Death of Lajos SZABO

64y · Male·metastatic adenocarcinoma of the lung (palliated)

Lajos Szabo, a 64-year-old prisoner, died from metastatic adenocarcinoma of the lung with brain metastases. He presented to prison medical services in November 2018 with neck swelling and fever, was promptly investigated…

general practicerespiratory medicine
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 cardiopulmonary complic…

paediatricsrespiratory medicinecommunicationsystem
WAhospital2021-03-08

Inquest into the Death of Stephen Craig SOLLY

63y · Male·respiratory failure in a man with lung cancer, chronic obstructive pulmonary dis…

Stephen Craig Solly, aged 63, died from respiratory failure due to advanced lung cancer, COPD, and pulmonary fibrosis while an involuntary psychiatric patient at Graylands Hospital. He had paranoid schizophrenia, cogniti…

psychiatryrespiratory medicineduloxetine
WAhospice2021-01-15

Inquest into the Death of Stuart William DUGAN

70y · Male·carcinoma of the lung

Stuart Dugan, a 70-year-old prisoner with advanced lung cancer, died in hospice care. He had multiple missed opportunities for earlier diagnosis. While smoking-related lung cancer commonly presents late with poor prognos…

general practicerespiratory medicinediagnosticcommunicationtramadol
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
WAhospital2020-12-02

Inquest into the Death of Simon John SHARPE

Male·non-specific interstitial pneumonia

Simon John Sharpe, a sentenced prisoner with incurable non-specific interstitial pneumonia, died on 30 June 2017 at Fiona Stanley Hospital from progression of his lung disease. Throughout his 17-month imprisonment, Sharp…

respiratory medicinetransplant medicine
WAhospital2020-06-03

Inquest into the Death of Michael Warren DYBALL

56y · Male·bronchopneumonia complicated by multiorgan failure and hypoxic ischaemic encepha…

Michael Dyball, a 56-year-old prisoner with chronic kidney disease, hepatitis C, and treated oropharyngeal squamous cell carcinoma, collapsed in his prison cell and suffered cardiopulmonary arrest on 28 April 2016. He di…

nephrologyoncologydarbepoetin alfa
WAhospital2020-03-27

Inquest into the Death of Alexander Robert EATTS

73y · Male·Complications, including multi-organ failure and pneumonia, of chronic obstructi…

Alexander Robert Eatts, a 73-year-old prisoner with severe chronic obstructive pulmonary disease (COPD), congestive cardiac failure, and multiple comorbidities, died from complications of COPD including multi-organ failu…

respiratory medicinecardiology
WAhospital2020-03-20

Inquest into the Death of Norman Alexander HAZELGROVE

73y · Male·metastatic carcinoma of the lung with palliation

Norman Hazelgrove, a 73-year-old prisoner, died from metastatic lung carcinoma in September 2017. Early in his imprisonment (2013), a chest X-ray showed COPD but this diagnosis was not formally documented or managed desp…

respiratory medicineoncologydiagnosticsystemantihypertensive medication
WAhospital2019-12-20

Inquest into the Death of Child TJW

7y · Female·aspiration pneumonia leading to multi-organ failure in a female child with compl…

A child with severe cerebral palsy, hypoxic ischaemic encephalopathy, microcephaly and seizure disorder died of aspiration pneumonia leading to multi-organ failure. Born with severe perinatal brain injury, she had comple…

paediatricsneurologymorphine
WAhospital2019-11-21

Inquest into the Death of Child SH

5y · Male·aspiration pneumonia with terminal palliative care, in a male child with complex…

A 5-year-old boy with severe congenital myopathy and arthrogryposis died from aspiration pneumonia following terminal palliative care. He had multiple complex medical needs including unsafe swallowing, recurrent respirat…

paediatricsrespiratory medicinesystemmorphine
WAhospital2019-08-30

Inquest into the Death of James Ronald CHI

69y · Male·Chronic obstructive pulmonary disease and coronary artery atherosclerosis

James Ronald Chi, aged 69, died from chronic obstructive pulmonary disease and coronary artery atherosclerosis at Broome Hospital. He was an involuntary mental health patient with treatment-resistant bipolar disorder and…

psychiatryemergency medicineclozapine
WAhospital2019-07-30

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

7y · Male·cardiorespiratory failure in a child with cerebral palsy and epilepsy, with acut…

Child KT (Vinnie), age 7, died of cardiorespiratory failure from cerebral palsy and epilepsy after a prolonged hospital admission. He had complex medical needs including chronic respiratory disease, requiring PEG feeding…

paediatricsintensive caresystemmorphine
WAhospital2019-07-09

Inquest into the Death of Troy Michael CONLEY

45y · Male·severe chronic obstructive pulmonary disease

Troy Michael Conley, aged 45, died from severe chronic obstructive pulmonary disease (COPD) while imprisoned. He had developed progressive lung disease from occupational exposure to gyprock dust, intravenous drug use (ta…

respiratory medicinegeneral medicinedelaymethadone
WAhospital2019-05-31

Inquest into the Death of Aurelio Monterlegre CRUZ

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

Aurelio Monterlegre Cruz, an 80-year-old man with complex medical conditions including chronic renal failure, ischaemic heart disease, diabetes, and COPD, died of bronchopneumonia complicating terminal palliative care wh…

nephrologypalliative carecommunicationdelayinsulin
WAhospice2019-05-31

Inquest into the Death of Colin George GRAHAM

56y · Male·disseminated malignancy – known non-small cell carcinoma of lung

Colin George Graham, a 56-year-old Aboriginal man with severe COPD and lung cancer, died of disseminated non-small cell carcinoma while in prison custody receiving palliative care. The coroner found his medical care was …

respiratory medicineoncology
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. Initially admitted to ED where she was sedat…

psychiatryemergency medicinecommunicationsystemchlorpromazine
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 decompensat…

psychiatryrespiratory medicinediagnosticcommunicationhaloperidol

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