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SAhospital2014-11-28

Coroner's Finding: HOGAN Constance Mary

73y · Female·general inanition due to dysphagia on a background of multiple neurological and …

A 73-year-old woman with bipolar disorder, alcohol abuse history, and multiple medical comorbidities presented with stroke-like symptoms in March 2012. Neuroimaging was unrevealing. She was detained under the Mental Heal…

neurologypsychiatry
SA2014-11-28

Coroner's Finding: MAYGER John Christopher

58y · Male·Ischaemic and hypertensive heart disease

John Christopher Mayger, aged 58, died of ischaemic and hypertensive heart disease while in custody at Adelaide Pre-release Centre. He had a significant cardiac history including two previous myocardial infarctions with …

cardiologyemergency medicinerosuvastatin
SAaged care2014-11-28

Coroner's Finding: RUSSELL Agnes Gillon

75y · Female·intracranial haemorrhage

A 75-year-old woman with frontal lobe dementia subject to a Guardianship Order died from intracranial haemorrhage at an aged care facility. She sustained a fall from a dining chair on 14 January 2012 and was transferred …

neurosurgerypalliative care
SAhospital2014-11-14

Coroner's Finding: KEY George Darcy

0y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…

George Darcy Key, an 8-day-old neonate, died from perinatal hypoxic ischaemic encephalopathy following labour complicated by excessive syntocinon-induced contractions and delayed obstetric intervention. The infant was de…

obstetricsanaesthesiadiagnosticcommunicationoxytocin
SAhome2014-09-05

Coroner's Finding: HARRISON Noah Alexander Edward

0y · Male·unascertained; possibly asphyxiation related to sleeping position

Noah Harrison, aged 12 weeks, died of unascertained cause in October 2010. He was found face-down in a pram with unsafe sleeping arrangements. At prior hospital admission on 17 September 2010 for fever and reported haema…

emergency medicinepaediatricsdiagnosticcommunication
SA2014-08-13

Coroner's Finding: O'DONOHOE Troy

32y · Male·Self-inflicted gunshot wound to head

Troy O'Donohoe, 32, died from a self-inflicted gunshot wound to the head while intoxicated (BAC 0.236%) and evading police. He had recently acquired a firearm despite a drink-driving conviction with a very high blood alc…

system
SAhospital2014-07-08

Coroner's Finding: SLEEP Aurora Doreen Maureen

4y · Female·hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to…

Aurora Sleep died from hypoxic-ischaemic encephalopathy caused by uterine rupture during labour induction with prostaglandin gel. Her mother had a perforated uterus from a D&C procedure 9 months earlier. The coroner foun…

obstetricsmidwiferycommunicationdiagnosticprostaglandin gel
SAcommunity2014-07-07

Coroner's Finding: ABRAHIMZADEH Zahra

44y · Female·incised wound to the chest with superior pulmonary artery injury

Zahra Abrahimzadeh, aged 44, was stabbed to death by her estranged husband Ziaolleh in March 2010 at a Persian New Year event. Despite reporting repeated domestic violence to police in February 2009, Ziaolleh was never a…

diagnosticcommunication
SAcommunity2014-06-17

Coroner's Finding: HUGO-HORSMAN Jason William

15y · Male·compression of the neck consistent with hanging

Jason Hugo-Horsman, a 15-year-old in Year 10, died by hanging while alone at home on 9 October 2010. He had been referred to Child and Adolescent Mental Health Services (CAMHS) in December 2009 and saw various therapists…

psychiatrypsychologydiagnosticcommunicationdiazepam
SAhome2014-06-17

Coroner's Finding: KOLBIG Drew Robin

37y · Male·stab wound to the chest penetrating the heart

A 37-year-old man with schizophrenia and a history of command auditory hallucinations died by self-inflicted stab wound to the chest. Released from psychiatric hospital on 11 April 2011 on voluntary arrangements without …

psychiatryoccupational therapydiagnosticcommunicationquetiapine
SAhospital2014-05-19

Coroner's Finding: AYRES David Stanley

65y · Male·sepsis due to aspiration pneumonia

David Stanley Ayres, aged 65, died from sepsis due to aspiration pneumonia while in hospital detention under a Mental Health Act order. He presented to his GP on 8 June 2011 with suspected urinary tract infection and was…

general practiceintensive caresystemcefalexin
SAhospital2014-05-19

Coroner's Finding: DONNELL Kevin George

60y · Male·end stage refractory chronic congestive cardiac failure on a background of chron…

A 60-year-old man with chronic schizophrenia, end-stage cardiac failure, renal failure, and dementia died of refractory congestive heart failure while under Mental Health Act detention. He had multiple comorbidities incl…

cardiologypsychiatry
SAhospital2014-05-19

Coroner's Finding: SGAMBATO Raffaele

84y · Male·malnutrition in conjunction with heart, liver and kidney failure

An 84-year-old man with severe dilated cardiomyopathy, atrial fibrillation, chronic renal failure, and behavioural disturbance was admitted to Royal Adelaide Hospital following a fall. He displayed acute psychiatric symp…

cardiologypsychiatrymorphine
SAhome2014-04-17

Coroner's Finding: KEITH George

80y · Male·gunshot wound to the head

An 80-year-old man with chronic back pain died by self-inflicted gunshot wound to the head on 1 March 2011. Five days before his death, he mentioned suicide using a rifle to his long-term general practitioner, Dr D., but…

general practiceorthopaedic surgerydiagnosticcommunicationoxycodone
SAhospital2014-04-17

Coroner's Finding: TABB Charles Andrew

50y · Male·multi-organ failure due to pancreatitis and generalised varicella zoster virus i…

Charles Andrew Tabb, a 50-year-old prisoner with non-Hodgkin's lymphoma (diagnosed 13 years prior, treated with bone marrow transplants), died of multi-organ failure from pancreatitis and disseminated varicella zoster vi…

haematologyinfectious diseases
SAaged care2014-04-17

Coroner's Finding: WERNER Cynthia Joy

76y · Female·colchicine toxicity

A 76-year-old woman with gout died from colchicine toxicity after being prescribed 500µg three times daily on 9 December 2010 for an acute attack. She developed diarrhoea from 15 December and died on 19 December with a p…

general practicegeriatric medicinemedicationsystemcolchicine
SAaged care2014-03-21

Coroner's Finding: MORGAN Beryl Jean

73y · Female·pneumonia and renal failure with hyperthermia

Beryl Jean Morgan, 73-year-old aged care resident, died from pneumonia and renal failure with hyperthermia after a brief hospital admission. She had been prescribed haloperidol for behavioural problems; while neuroleptic…

general practicegeriatric medicinediagnosticcommunicationhaloperidol
SAcommunity2014-03-12

Coroner's Finding: MUNDY Michaela Jayne

15y · Female·neck compression due to hanging

Michaela Mundy, a 15-year-old with depression, was seen by CAMHS therapist Vina Hotich from July-November 2011, presenting with suicidal ideation, self-harm, and moderate-to-severe depressive symptoms. Despite evidence o…

psychiatrygeneral practicediagnosticcommunicationfluoxetine
SAhospital2014-02-14

Coroner's Finding: RYAN John William and WALTON Patricia Dawn

Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…

Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…

anaesthesiaorthopaedic surgerydiagnosticcommunicationmorphine
SAhospital2014-02-05

Coroner's Finding: COOK Eileen Hazel

76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…

Mrs Cook, a 76-year-old woman, died in January 2010 from hospital-acquired pneumonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangerously…

general practiceemergency medicinediagnosticcommunicationintravenous fluids
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