Coronial

582 results for ischaemic_heart_disease

QLDhospital2013-04-16

Hornby, Geoffrey John

58y · Male·Respiratory failure due to or as a consequence of Chronic Obstructive Pulmonary …

Geoffrey Hornby, a 58-year-old prisoner with significant COPD, ischemic heart disease, and multiple comorbidities, died from respiratory failure secondary to COPD. He was admitted to hospital with COPD exacerbation and d…

respiratory medicineemergency medicinecommunicationdelaysalbutamol
VIChospital2020-01-31

Finding into death of Brett Maybus

60y · Male·Haemorrhage complicating a left robotic upper mediastinal lymph node clearance i…

Brett Maybus, aged 60, died from massive haemorrhage following robotic mediastinal lymph node dissection for recurrent metastatic squamous cell carcinoma. The coroner found the fatal bleed was likely caused by rupture of…

cardiothoracic surgeryoncologycommunicationsystem
VIC2011-09-30

Finding into death of Jacqueline Mary Henderson

33y · Female·Injuries sustained as a result of aviation accident—specifically, controlled fli…

A Piper PA-31T Cheyenne aircraft collided with terrain near Benalla, Victoria on 28 July 2004, killing all six occupants including pilot Kerry Endicott and passenger Jacqueline Henderson. The pilot was highly experienced…

aviation medicinecardiologycommunicationsystemverapamil
QLDaged care2019-02-12

Quayle, Betty Christine - Non-inquest findings

89y · Female·Blunt force head injury on a background of ischaemic and valvular heart disease

An 89-year-old woman with dementia and cardiac disease died from blunt force head injury sustained during an assault by another resident with alcohol-related dementia in an aged care facility. The resident had a document…

geriatric medicinegeneral practicesystemcommunication
VIChospital2025-04-03

Finding into death of Alan John Trevor Deem

67y · Male·Intracranial haemorrhage complicating coronary artery bypass graft surgery follo…

A 67-year-old man died from intracranial haemorrhage following coronary artery bypass graft surgery. He had suffered a right coronary artery dissection during percutaneous coronary intervention at Sunshine Hospital and w…

cardiologycardiothoracic surgerycommunicationsystemdual anti-platelet agents
QLDaged care2024-12-10

Non-inquest findings into the death of Mr O.

79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…

A 79-year-old man with extensive comorbidities died following multiple falls in residential aged care. He was identified as high falls risk on admission but experienced inadequate falls prevention after a second fall on …

geriatric medicineemergency medicinediagnosticmedicationaspirin
ACThospital2023-01-30

Inquest into the Death of Maarouf El-Cheikh

57y · Male·streptococcus pneumonia septicaemia due to splenectomy

Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…

emergency medicineintensive carediagnosticmedicationceftriaxone
WAhospital2021-09-29

Inquest into the Death of Robert Charles CRAIG

73y · Male·Disseminated malignancy (advanced lung carcinoma and mouth carcinoma) in a man w…

Robert Craig, aged 73, died from disseminated malignancy (advanced lung and mouth carcinoma) while in prison custody. He received suboptimal cancer treatment at Fiona Stanley Hospital due to communication failures betwee…

oncologyradiation oncologydiagnosticcommunicationcetuximab
VIChospital2026-04-28

Finding into death of Ronald William Beaumont

74y · Male·Acute myocardial infarction complicated by multiple organ failure

Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…

cardiologyorthopaedic surgerymedicationcommunicationaspirin
SA2006-05-22

Coroner's Finding: GEORGE Patricia Nina

81y · Female·aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphy…

Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive heart failure. A critical ambulance transfer delay …

psychiatryemergency medicinecommunicationsystemsalbutamol
NSWaged care2025-01-24

Inquest into the deaths at Newmarch House

Unknown·COVID-19 infection with various comorbidities as contributing factors

This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…

geriatric medicineinfectious diseasessystemdiagnosticmorphine
VIChospital2025-10-28

Finding into death of Jean Elizabeth Crocker

90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …

A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …

emergency medicinegeneral medicinemedicationdiagnosticwarfarin
VICmental health2017-06-29

Finding into death of Peter James Nolan

75y · Male·Hanging

Peter Nolan, a 75-year-old man with depression, chronic pain, alcohol dependence, and recent suicide attempts, died by hanging in an aged psychiatric mental health unit. He was admitted to Broadmeadows Aged Psychiatric M…

psychiatrygeriatric medicinesystemcommunicationsertraline
QLDhospital2016-02-29

Mr B - Non-inquest findings

84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…

An 84-year-old man with multiple comorbidities was prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed,…

cardiologyhaematologymedicationcommunicationrivaroxaban
VICaged care2013-12-18

Finding into death of Caterina Montalto

76y · Female·Immersion (with underlying cause undetermined in circumstances of a fall into a …

76-year-old woman with vascular dementia and wandering behaviour was found submerged in a courtyard water fountain at an aged care facility after a fall. She remained unattended in a hazardous area for approximately 51 m…

geriatric medicinegeneral practicecommunicationsystemdiazepam
WAhospital2022-01-17

Inquest into the Death of Peter Johnnie YOUNG

Male·Complications of alcohol and hepatitis C-related liver disease

Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…

hepatologygastroenterologysystemdelayquetiapine
SAhospital2005-06-02

Coroner's Finding: GREEN Marie

64y · Female·Respiratory arrest secondary to morphine overdosage on a background of mild to m…

A 64-year-old woman died from respiratory arrest secondary to morphine overdose after ingesting 17 tablets of slow-release morphine (Kapanol) and diazepam. Initial emergency assessment by an intern was appropriate, but c…

emergency medicinegeneral medicinecommunicationdiagnosticmorphine
WAhospital2007-05

Inquest into the Death of frith

80y · Female·Pulmonary Thromboembolism in a woman with Left Femur Fracture

Sheila Margaret Frith, 80, sustained a left femur fracture after falling at the top of an escalator at an immigration office on 4 July 2005. She was admitted to Sir Charles Gairdner Hospital for urgent surgical repair. H…

orthopaedic surgeryanaesthesiacommunicationsystemsolprin
VIC2011-09-30

Finding into death of Belinda Anne Andrews

34y · Female·Injuries sustained as a result of aviation accident (collision with terrain)

On 28 July 2004, Belinda Anne Andrews, aged 34, died along with five others when Piper PA-31T aircraft VH-TNP collided with terrain near Benalla, Victoria during a GPS approach in instrument meteorological conditions. Th…

aviation medicinecardiologycommunicationsystemverapamil
VICaged care2022-10-14

Finding into death of Beryl Eileen Brindley

74y · Female·Diabetic ketoacidosis

A 74-year-old woman with Type 1 diabetes died from diabetic ketoacidosis (DKA) in an aged care facility. Between 7-10 December 2016, her blood glucose levels remained persistently elevated (>33 mmol/L) despite escalating…

general practiceendocrinologydiagnosticcommunicationinsulin

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