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SAhome2025-11-27

Coroner's Finding: Nguyen, Van Tam

47y · Male·self-inflicted stab wound to the chest with penetration of the left ventricle of…

A 47-year-old man serving his sentence on home detention died from a self-inflicted stab wound to the chest. He had a history of heroin and methamphetamine use and was receiving methadone maintenance and mirtazapine whil…

correctional healthpsychiatryheroin
SAhospital2025-11-14

Coroner's Finding: Menzies, Jason Douglas

33y · Male·Marburg variant of multiple sclerosis

Jason Menzies, aged 33, died in custody from Marburg variant multiple sclerosis after rapid neurological deterioration. He initially presented with urinary retention on 1 December 2022, which was appropriately investigat…

emergency medicinegeneral medicineamitriptyline
SA2025-11-14

Coroner's Finding: Porter, Peter Raymond

65y · Male·metastatic prostate cancer complicated by deep vein thromboses

Peter Raymond Porter, aged 65, died in prison from metastatic prostate cancer complicated by deep vein thromboses in January 2022, eight and a half years after diagnosis. He had presented with urinary symptoms in Decembe…

oncologyurologyduodart
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
SAhome2025-11-13

Coroner's Finding: Platten, Garry David

72y · Male·hypoxic brain injury due to cardiac arrest due to compression of the neck due to…

A 72-year-old man on home detention bail for alleged sexual offending died by hanging after experiencing cumulative stressors. Key events included arrest, placement on home detention, and subsequent media coverage of cha…

emergency medicineintensive care
SAhospital2025-11-05

Coroner's Finding: Jackson, Dennis Charles

67y · Male·Type 2 respiratory failure due to pneumonia

Dennis Jackson, a 67-year-old from Broken Hill, underwent left upper lobe lobectomy based on a falsely positive lung biopsy contaminated with squamous cell carcinoma tissue from another patient during processing at SA Pa…

cardiothoracic surgerypathologydiagnosticsystem
SAcommunity2025-10-20

Coroner's Finding: Kennedy, John Douglas

65y · Male·Ischaemic heart disease on a background of hypertension

John Kennedy, 65, died from ischaemic heart disease with hypertension on 16 April 2020 after a 24-minute delay in ambulance dispatch. He called triple zero at 00:19 with severe chest pain and difficulty breathing (Priori…

emergency medicinecardiologycommunicationsystematenolol
SAcommunity2025-10-17

Coroner's Finding: Hall, Robert Lloyd

66y · Male·multiple injuries sustained in motor vehicle collision

A 66-year-old cyclist was struck and killed from behind by a driver with left absolute homonymous hemianopia (left-sided visual field loss) who was not scanning to compensate for his disability. The driver had suffered a…

neurosurgeryneurologysystemcommunication
SAaged care2025-09-11

Coroner's Finding: Glenn, Millicent

89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…

An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…

general practicegeriatric medicinemedicationdiagnosticgentamicin
SAaged care2025-08-28

Coroner's Finding: Andrysik, Anne Carol

80y · Female·Fractured left neck of femur on a background of rectal carcinoma and dementia

An 80-year-old woman with dementia and undiagnosed rectal carcinoma died from complications of a fractured left neck of femur sustained during a fall in her aged care facility's memory support unit. She had sustained thr…

geriatric medicinegeneral practicenorspan patch
SA2025-08-28

Coroner's Finding: RJR

65y · Male·metastatic rectal cancer with extensive lung metastases

A 65-year-old man died from metastatic rectal cancer with extensive lung metastases while serving a prison sentence. He had presented with rectal bleeding symptoms since 2011 and returned a positive faecal occult blood t…

colorectal surgeryoncologyapixaban
SAhospitalPodcast2025-07-31

Coroner's Finding: Panella, Anna Vincenza and Skeffington, Bernard Anthony and Jessett, Graham Henry

Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…

Three South Australians died following extended waits on ambulance ramps outside metropolitan hospitals. Anna Panella (76) died from pulmonary thromboembolism; Bernard Skeffington (89) died from aspiration pneumonia afte…

emergency medicinecardiologycommunicationsystem
SAhospital2025-07-03

Coroner's Finding: Provis, Adam James

50y · Male·in-hospital cardiac arrest on a background of seizures and atheroembolic cerebro…

A 50-year-old man with bipolar affective disorder, hypertension, anxiety, depression and history of alcohol abuse died from in-hospital cardiac arrest on a background of seizures and atheroembolic cerebrovascular disease…

psychiatryneurologythiamine
SAhospital2025-07-03

Coroner's Finding: Cheesman, Trevor Allan

70y · Male·complications arising from craniofacial resection and orbital exenteration for r…

A 70-year-old man died following complex craniofacial resection and orbital exenteration for right sinonasal adenocarcinoma. Multiple surgical complications occurred including carotid artery injury, cerebral infarction, …

neurosurgeryENT surgerysystemolanzapine
SAhospital2025-06-12

Coroner's Finding: Salter, Kathleen Ethel

76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy

A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the com…

general surgeryanaesthesiadiagnosticproceduralapixaban
SAhospital2025-06-11

Coroner's Finding: OHalloran, Emma Louise

48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam

A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…

cardiologygeneral practicesystemcommunicationflecainide
SA2025-06-03

Coroner's Finding: Sears, James Frank

53y · Male·disseminated malignant melanoma

A 53-year-old man died of disseminated malignant melanoma while incarcerated at Yatala Labour Prison. Initial excision of a large arm mole in November 2019 revealed Stage III melanoma. A January 2020 multi-disciplinary t…

dermatologyoncologycommunicationsystemdabrafenib
SAhospital2025-05-20

Coroner's Finding: Foster, Stephen John

74y · Male·acute on chronic liver failure complicating common bile duct cholangiocarcinoma …

Stephen John Foster, aged 74, died in hospital from acute on chronic liver failure complicating common bile duct cholangiocarcinoma. He was serving a prison sentence at the time. Initial presentation with jaundice, eleva…

correctional healthsurgery
SAhospital2025-05-20

Coroner's Finding: Freeman, Keith Vivian

71y · Male·end-stage cardiac failure on a background of ischaemic heart disease with dilate…

Keith Freeman, aged 71, died in custody from end-stage cardiac failure with ischaemic heart disease and dilated cardiomyopathy. He had complex cardiac history including previous CABG, aortic valve replacement, and implan…

cardiologyemergency medicinedelayfurosemide
SAhome2025-05-20

Coroner's Finding: Johnstone, Aaron George

43y · Male·methylamphetamine and heroin toxicity

A 43-year-old man died from methylamphetamine and heroin toxicity while on home detention bail. He had a complex psychiatric history including depression, psychosis, PTSD, and polysubstance use disorder, with previous su…

psychiatryaddiction medicinemethamphetamine

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