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VIChospital2021-10-25

Finding into death of MR XH

46y · Male·Hypoxic ischaemic brain injury complicating a cardiac arrest during anaesthetic …

A 46-year-old male underwent elective inguinal hernia repair at a private hospital. During anaesthetic induction, he experienced cardiac arrest. The endotracheal tube (ETT) was visualized passing through the vocal cords,…

anaesthesiaintensive carediagnosticproceduralfentanyl
NSWhospital2021-10-12

Inquest into the death of Bruce HODGES

78y · Male·cardiorespiratory failure due to complications of tracheal stenosis

Bruce Hodges, a 78-year-old man with a 20-year-old tracheostomy following laryngeal cancer surgery, presented to hospital with progressive shortness of breath and tracheal stenosis. Over 48 hours of admission, his respir…

emergency medicineENT surgerydiagnosticsystemnebulised saline
VICcommunity2021-10-01

Finding into death of Stuart Anthony Wills

45y · Male·Aspiration of food bolus, with cerebral palsy as contributing factor

Stuart Wills, a 45-year-old man with cerebral palsy and severe dysphagia, died from aspiration of a food bolus while receiving meal assistance at a supported accommodation facility. Prior to his death, a speech pathologi…

speech pathologyemergency medicineproceduraladrenaline
VIChospital2021-09-30

Finding into death of James Owen Lynch

71y · Male·Aspiration pneumonia in a man with intellectual disability

A 71-year-old man with intellectual disability and chronic aspiration risk died from aspiration pneumonia leading to cardiac arrest. He had a longstanding history of dysphagia with multiple previous aspiration episodes d…

emergency medicineintensive careamoxicillin
NSWcommunity2021-09-23

Inquest into the death of M F

46y · Male·blunt force injuries from motor vehicle collision with a tree

A 46-year-old Aboriginal man died by suicide following a motor vehicle collision with a tree while being pursued by police responding to a welfare check. He had a complex history of depression, amphetamine addiction (ice…

general practicepsychiatrysystemdelayamphetamine
VIChospital2021-09-21

Finding into death of AH

37y · Male·Mixed Drug Toxicity (Oxycodone, Quetiapine, Pregabalin and Clonazepam)

A 37-year-old man died from mixed drug toxicity (oxycodone, quetiapine, pregabalin, clonazepam) after ingesting unknown quantities of his own medications in an ED. He presented with trauma symptoms four days post-motor v…

emergency medicinetoxicologydiagnosticcommunicationoxycodone
TAShospital2021-09-20

Coroner's Finding: Suter, Nigel Douglas

Male·respiratory failure from blunt trauma to the chest sustained in a motor vehicle …

Nigel Douglas Suter died from respiratory failure caused by blunt chest trauma sustained in a motor vehicle crash on 16 April 2021. He collided with a gumtree on Argonaut Road, St Helens, after his vehicle left the road.…

intensive caretrauma surgerycannabis
VIChospital2021-09-02

Finding into death of Robena May Lloyd

58y · Female·Enterococcus faecalis sepsis and acute renal failure

Robena Lloyd, a 58-year-old woman with intellectual disability and schizophrenia, died from enterococcus faecalis sepsis and acute renal failure on 7 August 2009. She presented to Angliss Hospital ED on 31 July with urin…

emergency medicinenephrologydiagnosticcommunicationtrimethoprim
TAShospital2021-08-26

Coroner's Finding: PY

0y · Unknown·sepsis leading to multiple organ failure syndrome

A 48-day-old neonate with congenital heart defect presented to the ED with fever and vomiting on 20 September 2019. Initial triage as Category 3 was inappropriate; the child required urgent assessment. The ED intern saw …

paediatricsemergency medicinediagnosticdelayparacetamol
VIChospital2021-08-26

Finding into death of 'Child A'

15y · Unknown·acute respiratory distress syndrome resulting from multi-organ failure as a cons…

Child A, aged 15, died from acute respiratory distress syndrome resulting from multi-organ failure due to disseminated tuberculosis. He presented to hospital with very advanced post-primary pulmonary tuberculosis requiri…

respiratory medicinepaediatricsdelay
TAShospital2021-08-23

Coroner's Finding: Cooper, Melanie Sarah 2021 TASCD 475

51y · Female·embolic infarcts complicating infective endocarditis

Melanie Sarah Cooper, aged 51, died from embolic infarcts complicating infective endocarditis secondary to chronic intravenous opioid use. She presented with severe physical deterioration over three days including swolle…

intensive careinfectious diseasesdelaymorphine
TAShospital2021-08-20

Coroner's Finding: LA

67y · Male·acute gastrointestinal haemorrhage complicating peptic ulcer of the duodenum wit…

A 67-year-old man died from acute gastrointestinal haemorrhage from a duodenal ulcer following complex post-operative complications from laparoscopic Hartmann's procedure for diverticulitis. Key clinical lessons: (1) Ear…

general surgeryintensive carediagnosticmedicationrabeprazole
QLD2021-08-20

Caramin, Olivier Max - Non-inquest findings

27y · Male·multiple organ failure due to or as a consequence of heat stroke

Olivier Caramin, a 27-year-old Belgian national on a working holiday visa, died from heat stroke while picking pumpkins on 31 October 2017 in Far North Queensland. He was just three days into farm work without proper acc…

occupational and environmental healthemergency medicinesystemdiagnostic
VIChospital2021-08-16

Finding into death of XA

39y · Male·Complications arising from widely disseminated primary pulmonary small cell carc…

A 39-year-old male inmate died from complications of widely disseminated small cell lung cancer with hepatitis C cirrhosis. He presented with acute psychosis and catatonia in December 2018, receiving appropriate psychiat…

psychiatryoncologyolanzapine
VIChospital2021-08-16

Finding into death of David John Main

54y · Male·Toxic leukoencephalopathy (of uncertain aetiology)

David Main, 54, died from toxic leukoencephalopathy of uncertain aetiology following a ketamine-assisted oxycodone detoxification at Beleura Private Hospital. He had chronic pain from multiple injuries and opioid depende…

pain medicineanaesthesiaketamine
TAShospital2021-08-13

Coroner's Finding: Mrs M

Female·multi-organ failure

Mrs M died from multi-organ failure following recurrent intra-abdominal sepsis and surgical complications after endoscopic duodenal perforation in June 2019. During resection of a duodenal adenoma, perforation occurred r…

gastroenterologygeneral surgerydiagnostic
WAhospital2021-08-06

Inquest into the Death of Hassan Mohamed YOUSSEF

60y · Male·Complications of gastrointestinal haemorrhage due to cirrhosis of the liver seco…

Hassan Mohamed Youssef, a 60-year-old sentenced prisoner, died from gastrointestinal haemorrhage complications secondary to cirrhosis from hepatitis B. He presented with multiple serious pre-existing conditions including…

gastroenterologyhepatology
WAhospital2021-08-06

Inquest into the Death of Alex Carl MILLS

76y · Male·Sepsis, with osteomyelitis and infective endocarditis

Alex Mills, a 76-year-old sentenced prisoner with complex medical history including atrial fibrillation, valvular heart disease, and rheumatoid arthritis, died from sepsis caused by osteomyelitis and infective endocardit…

infectious diseasescardiologydiagnosticdelayprednisolone
VIChome2021-08-04

Finding into death of NB

1y · Male·Global cerebral ischaemia in an infant with upper airway obstruction

NB, a 14-month-old with a tracheostomy requiring overnight nursing support in foster care, suffered a cardiac arrest on 17 December 2016 that resulted in severe hypoxic brain injury and death. The overnight nurse (Ms Jar…

respiratory medicineintensive carediagnosticcommunication
VIChome2021-08-02

Finding into death of Mark Marian Milewski

71y · Male·Mixed drug toxicity

A 71-year-old man with multiple chronic conditions including obesity, diabetes, heart failure, and chronic pain died from mixed drug toxicity involving oxycodone, codeine, diazepam, and alcohol. The coroner determined he…

general practicegeriatric medicinediagnosticoxycodone
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