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SAhospital2022-06-10

Coroner's Finding: Bertram, Kerry Anne

42y · Female·multiorgan failure complicating hyperthermia and metabolic acidosis following su…

A 42-year-old woman with long-standing depression, substance use issues, and multiple mental health presentations died from multi-organ failure following ingestion of caustic soda. She was found unresponsive at home on 1…

intensive carepsychiatryalcohol
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
NSWhome2022-06-07

Findings - AD & Aleksander Stefanovic

Male·Gunshot wound to chest (Aleksander Stefanovic); gunshot wound to head (AD)

Joint inquest into the deaths of two males at their shared Lewisham home on 4 September 2020. AD (aged 55), with documented depression, anxiety and recent suicidal ideation, shot his flatmate Aleksander Stefanovic (aged …

emergency medicineparamedicine
NSWhospital2022-05-30

Inquest into the death of Alex BRAES

18y · Male·Multi organ failure due to sepsis from a Group A streptococcus infection

Alex Braes, an 18-year-old from Broken Hill NSW, died of multi-organ failure due to Group A streptococcus sepsis. He presented to Broken Hill Base Hospital three times over 24 hours with knee pain that progressed to seps…

emergency medicineinfectious diseasessystemdelayceftriaxone
TAShome2022-05-27

Coroner's Finding: TS de-identified

47y · Female·Traumatic closed head injury likely sustained in a fall from standing

TS, a 47-year-old woman with a 18-year history of anorexia nervosa, bulimia, and severe alcoholism, died from a traumatic closed head injury sustained in a fall from standing. At autopsy, blood alcohol concentration was …

emergency medicinegeneral practicecommunicationsystemalcohol
WA2022-05-20

Inquest into the Death of Kevin Ernest McCRACKEN

58y · Male·Hypertensive and valvular heart disease

Kevin McCracken, 58, died of hypertensive and valvular heart disease following sudden cardiac collapse in a prison pre-release unit. He had complex pre-existing cardiac disease including previous valve replacement and ao…

cardiologycorrectional healthsystemmedicationwarfarin
VIChospital2022-05-09

Finding into death of Robert Albert Burns

75y · Male·Multiorgan dysfunction syndrome complicating anastomotic leak following hemicole…

A 75-year-old man died from multiorgan dysfunction following an anastomotic leak after hemicolectomy for caecal adenocarcinoma. Initial post-operative recovery appeared normal, but he deteriorated from day 3 onwards. The…

colorectal surgeryintensive carediagnosticdelay
VIChospital2022-05-06

Finding into death of Trevor Anthony Peterson

57y · Male·Sepsis from ischemic bowel due to superior mesenteric artery thrombus

Trevor Peterson, a 57-year-old with chronic gut ischemia, underwent mesenteric artery stenting in February 2020. Discharge instructions emphasising dual antiplatelet therapy (DAPT) were not clearly communicated to the va…

vascular surgeryradiologycommunicationsystemaspirin
VIChospital2022-05-05

Finding into death of PX O

49y · Male·Complications of a right superficial femoral artery injury (operated) following …

A 49-year-old man died from complications of a right superficial femoral artery injury sustained when he was struck by a circular saw at a landscaping worksite. Despite receiving immediate first aid, emergency transport …

trauma surgeryvascular surgerysystemcommunication
VICmental health2022-05-02

Finding into death of Stuart Brant Garten

34y · Male·Hypoxic/ischaemic brain injury following resuscitated cardiac arrest and hanging

Stuart Brant Garten, a 34-year-old man with complex psychiatric diagnoses including borderline personality disorder, post-traumatic stress disorder, and schizophrenia, died by hanging in the courtyard of a secure extende…

psychiatryintensive carecommunicationsystemrisperidone
VIChospital2022-04-28

Finding into death of Hunter Patrick Boyle

2y · Male·Consistent with drowning

Hunter Patrick Boyle, a 2-year-old boy, drowned in a farm dam while under the care of his grandfather. Hunter and his grandfather visited a neighbouring property to feed a horse; within 30 seconds to 1 minute of losing s…

emergency medicinepaediatricsmorphine
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
SAhospital2022-04-13

Coroner's Finding: Cook, Courtney Liza

20y · Female·multi-organ failure due to polypharmacy overdose

A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where i…

emergency medicinegastroenterologydiagnosticcommunicationparacetamol
VIChospital2022-04-13

Finding into death of Katrina Jarm

41y · Female·Aspiration pneumonia

Ms Jarm, a 41-year-old woman with a degenerative neurological disorder living in supported residential care, died from aspiration pneumonia complicated by acute respiratory distress syndrome. She developed symptoms of ga…

emergency medicineintensive care
NSWhospital2022-04-05

Inquest into the death of Ronald TURNER

81y · Male·Consequences of bowel obstruction

Ronald Turner, an 81-year-old man in lawful custody, died from consequences of bowel obstruction with aspiration pneumonia. He had a history of recurrent sigmoid volvulus despite previous surgery. On 22 January 2020, he …

colorectal surgerygeriatric medicine
SA2022-03-30

Coroner's Finding: Hohol, Peter

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

Peter Hohol, a 68-year-old prisoner with significant cardiac comorbidities including ischaemic and dilated cardiomyopathy, died from decompensated heart failure with pulmonary hypertensive crisis complicated by pneumonia…

cardiologygeneral medicine
VICmental health2022-03-30

Finding into death of B J

24y · Male·Hypoxic brain injury secondary to hanging

BJ, a 24-year-old with paranoid schizophrenia, substance abuse disorder, and anti-social personality disorder, died by hanging in a psychiatric unit after a suicide attempt. He was admitted on 4 January 2016 with suicida…

psychiatryemergency medicinecommunicationsystemquetiapine
WAhospital2022-03-28

Inquest into the Death of Morgan John EDWARDS

31y · Male·Complications in association with intestinal volvulus

31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…

emergency medicinegastroenterologydiagnosticcommunication
VIC2022-03-28

Finding into death of Deva Rebecca Frijlink

42y · Female·Choking on a food bolus

Deva Frijlink, aged 42 years with intellectual disability and schizoaffective disorder, died from choking on a food bolus during a supervised mealtime excursion. She was under the care of a support worker at a shared acc…

speech pathologyemergency medicinecommunicationsystemdiazepam
VIChospital2022-03-28

Finding into death of FJ L

24y · Male·Mixed drug toxicity (25C-NBOME, 4-fluoroamphetamine, LSD, MDMA, cocaine, ketamin…

A 24-year-old previously healthy male died from mixed drug toxicity after ingesting multiple substances (25C-NBOME, 4-fluoroamphetamine, LSD, MDMA, cocaine, ketamine) at a music festival. He presented to the Alfred Hospi…

emergency medicineintensive care25c-nbome
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