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SAhospital2011-11-03

Coroner's Finding: BALLARD Margaret Dawn

76y · Female·aspiration of gastro-intestinal contents as a result of small bowel obstruction …

A 76-year-old woman with Alzheimer's dementia and psychiatric illness collapsed on 1 January 2009 and was assessed in the Emergency Department. Dr B. diagnosed vasovagal syncope with gastroenteritis based on the patient'…

emergency medicinepsychiatrydiagnosticcommunicationsodium valproate
SAhospital2011-10-06

Coroner's Finding: BROWN Kunmanara

18y · Male·Hypoxic brain injury following cardiac arrest due to neck compression from hangi…

An 18-year-old Aboriginal man died from hypoxic brain injury following cardiac arrest from hanging. He had a chronic petrol-sniffing habit and was acutely intoxicated on petrol when he hanged himself after a police incid…

emergency medicineintensive carecommunicationsystempetrol
SAhospital2011-09-23

Coroner's Finding: ANDERSON Rosemary Joy

56y · Female·multi-organ failure due to anorexia nervosa

A 56-year-old woman with a long history of anorexia nervosa and a BMI of 10.3 died from multi-organ failure after admission to hospital. She was found on her bedroom floor, dehydrated and malnourished, and was involuntar…

psychiatryintensive care
SAhospital2011-09-23

Coroner's Finding: BLYTHE Dorothy Josephine

81y · Female·ischaemic bowel

An 81-year-old woman with longstanding depression and multiple comorbidities fell and fractured her humerus in March 2009. During rehabilitation, she became increasingly depressed and self-neglectful, refusing food and c…

psychiatrygeneral surgerydiagnosticdelay
SAhospital2011-09-23

Coroner's Finding: DUBBIOSO Roberto

34y · Male·cardiomegaly with contributing aspiration

A 34-year-old man with paranoid schizophrenia, morbid obesity, type 1 diabetes, and undiagnosed sleep apnoea died from cardiomegaly with contributing aspiration while detained under the Mental Health Act. On 6 March, he …

psychiatryemergency medicinediagnosticsystem
SAhospital2011-09-23

Coroner's Finding: HISCOCK Stephen West

90y · Male·aspiration pneumonia complicating community acquired pneumonia

A 90-year-old man died of aspiration pneumonia complicating community-acquired pneumonia while detained under the Mental Health Act following a suicide attempt. He presented with a sternal fracture and pneumonia, and was…

psychiatrygeneral medicine
SAhospital2011-09-20

Coroner's Finding: BELLOCCO (aka Ieva) Carmelina

61y · Female·respiratory failure secondary to advanced malignancy

Ms Carmelina Bellocco, aged 61, died from respiratory failure secondary to advanced metastatic colon cancer. She had longstanding paranoid schizophrenia with poor insight and compliance. Cancer was diagnosed in 2006 afte…

oncologycolorectal surgery
SAhospital2011-09-19

Coroner's Finding: FERME Susan Jane

47y · Female·acute subendocardial septal myocardial infarction complicating hypertension and …

A 47-year-old woman with hypertension, high cholesterol, and significant family history of early cardiac disease presented to a country hospital ED with acute crushing central chest pain (10/10), shortness of breath, and…

emergency medicinegeneral practicediagnosticcommunicationglyceryl trinitrate
SAaged care2011-09-19

Coroner's Finding: RICHARDSON Margaret Joan

63y · Female·ischaemic heart disease

Margaret Joan Richardson, aged 63, died of ischaemic heart disease at a private nursing home where she was detained under a Guardianship Board order. She had a long history of chronic alcohol abuse and cognitive impairme…

cardiologygeriatric medicine
SA2011-09-19

Coroner's Finding: RIGNEY Vincent Norman

35y · Male·ischaemic heart disease due to coronary atherosclerosis

A 35-year-old Aboriginal man died of ischaemic heart disease due to coronary atherosclerosis whilst in prison custody. He presented with chest pain and arm tingling at 6:20am but received only Panadol and Mylanta from no…

cardiologyemergency medicinediagnosticdelayparacetamol
SA2011-08-31

Coroner's Finding: ELLIOTT Stephen Brian

41y · Male·gunshot wound to chest

Stephen Brian Elliott, aged 41, died from a gunshot wound to the chest inflicted by a South Australian police officer during an armed apprehension operation. Elliott had attempted an armed robbery at a credit union earli…

tramadol
SAmental health2011-08-26

Coroner's Finding: REX Michael David

41y · Male·mixed drug toxicity (methadone, valproate, zuclopenthixol)

Michael David Rex, a 41-year-old man with chronic treatment-resistant paranoid schizophrenia, died from mixed drug toxicity (methadone, valproate, zuclopenthixol) while detained in Ward 5H of the Margaret Tobin Centre ps…

psychiatrypharmacysystemdelaymethadone
SAmental health2011-08-26

Coroner's Finding: XU Yan Yi

50y · Female·compression of the neck consistent with hanging

Yan Yi Xu, a 50-year-old woman with a history of depression and recent breast cancer diagnosis, was admitted to Cramond Clinic psychiatric ward following a suicide attempt on Christmas Day 2008. She died by hanging in he…

psychiatrygeneral practicediagnosticcommunicationsertraline
SAhospital2011-08-12

Coroner's Finding: PAXTON Donald Henry

83y · Male·ongoing respiratory failure from recurrent aspiration pneumonia, complicating de…

An 83-year-old man with dementia and suicidal ideation died from respiratory failure due to recurrent aspiration pneumonia. He was lawfully detained under a Guardianship Board order at a psychiatric hospital for 7 months…

geriatric medicinepsychiatrysertraline
SAhome2011-08-11

Coroner's Finding: PIRO Barbara Mary

91y · Female·pulmonary thromboembolism and subcutaneous abscess formation complicating pressu…

A 91-year-old woman died from pulmonary thromboembolism and abscess formation complicating untreated ankle fracture and pressure sores. She had sustained a fracture-dislocation of her right ankle after a fall, which she …

geriatric medicineemergency medicinedelaysystem
SAaged care2011-08-08

Coroner's Finding: BURNS John Arthur

63y · Male·cerebral infarction

John Arthur Burns, a 63-year-old man with frontotemporal dementia and motor neurone disease, died from cerebral infarction on 17 September 2006 while in Westminster Aged Care Facility after only 12 days of residence. Des…

general practicegeriatric medicinemedicationcommunicationhaloperidol
SAhospital2011-08-05

Coroner's Finding: LEONARD Emily Ruth and HILLMAN Glenys Anne

Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…

Two elderly women died following vaginal prolapse surgery performed by the same surgeon, Dr O., with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic surger…

gynaecologyintensive carediagnosticproceduralheparin
SAhospital2011-08-05

Coroner's Finding: SEMMLER Howard Malcolm

60y · Male·cardiorespiratory failure due to malignant pleural effusion due to metastatic ma…

A 60-year-old man with diabetes presented with a plantar heel ulcer in March 2007 that was initially treated as a diabetic foot ulcer. The lesion failed to heal over 16 months despite standard care including wound dressi…

general practiceorthopaedic surgerydiagnosticdelay
SAhospital2011-08-03

Coroner's Finding: GILL Dennis William

72y · Male·acute leukaemia on a background of ischaemic heart disease

Dennis William Gill, a 72-year-old man serving a suspended home detention sentence, died of acute leukaemia on a background of ischaemic heart disease after admission to Ashford Hospital in August 2009. He had significan…

haematologycardiology
SAmental health2011-07-13

Coroner's Finding: FARMER John Sydney

34y · Male·hanging

John Sydney Farmer, aged 34, died by hanging at his home on 23 May 2008, six hours after being granted leave from psychiatric detention at Woodleigh House. He had attempted suicide by carbon monoxide poisoning two days e…

psychiatryemergency medicinediagnosticcommunicationcitalopram
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