Coronial
VIChospital2010-05-31

Finding into death of Paul Alexander Goodwin

85y · Male·Ruptured abdominal aortic aneurysm

…e abdominal aortic aneurysm died from rupture of this aneurysm while hospitalized for acute exacerbation of COPD. A medication error occurred at admission when Dr T. inadvertently included medication lists from two other…

general medicinerespiratory medicinemedicationgabapentin
SAhospital2015-08-27

Coroner's Finding: O'LEARY Judith Beverley

75y · Female·exacerbation of end-stage chronic obstructive pulmonary disease

Judith Beverley O'Leary, 75-year-old woman with end-stage COPD, dementia, depression and multiple comorbidities, died from exacerbation of COPD with secondary respiratory…

respiratory medicineemergency medicinequetiapine
VIChospital2018-04-26

Finding into death of James Pickup

59y · Male·Pulmonary embolus

…lesterolaemia presented to the ED with two days of acute onset shortness of breath. The registrar diagnosed COPD based on normal vitals, clinical examination, normal ECG, and chest X-ray showing increased lung volumes. T…

emergency medicinerespiratory medicinediagnosticcommunication
SAhospital2024-05-16

Coroner's Finding: Fisher, Lynne Patricia

60y · Female·sepsis due to community acquired pneumonia

…neumonia risk-stratification scores (SMART-COP) despite available guidelines, and inappropriately diagnosed COPD without spirometry, setting dangerously low oxygen targets (88-92%); (2) Dr L. did not insist on admission …

emergency medicinegeneral practicediagnosticdelayamoxicillin/clavulanate
WAhospital

Inquest into the Death of Robert Paul RODDA

62y · Male·Multi-organ failure following surgical repair of ruptured abdominal aortic aneur…

…a, a 62-year-old long-term prisoner with extensive medical comorbidities including ischaemic heart disease, COPD, and a known abdominal aortic aneurysm (AAA), presented with chest pain in September 2015. Imaging revealed…

vascular surgerycardiology
NSW2021-11-08

Inquest into the death of Walter CLOUGH

66y · Male·Complications of chronic obstructive pulmonary disease. A significant contributi…

Walter Clough, aged 66, died from complications of COPD and cardiomegaly while incarcerated. He had significant respiratory compromise from prior chest trauma caus…

general practicerespiratory medicinesystemspriva
VICcommunity2023-09-21

Finding into death of Simaile Masila-Liutolo

35y · Male·Dilated cardiomyopathy and coronary atherosclerosis, in the setting of drug cons…

…ncrease adverse clinical effects. The deceased had significant cardiac risk factors (heart disease, asthma, COPD, obesity) making him susceptible to pulmonary and cardiac effects. The coroner found police actions reasona…

forensic medicinetoxicologymethamphetamine
NSWaged care2021-06-23

Inquest into the death of Victor Madeley

85y · Male·Diabetes mellitus and its complications

…t on 5 February 2020 from diabetes mellitus and its complications. He had extensive comorbidities including COPD, ischaemic heart disease, and asthma. He was transferred to the aged care unit after hospitalisation at Pri…

general medicinegeriatric medicine
SAaged care2020-05-28

Coroner's Finding: COCHRAN Henry Reginald

89y · Male·ischaemic heart disease and chronic obstructive pulmonary disease with aspiratio…

An 89-year-old man with ischaemic heart disease, COPD, dementia, and Korsakoff syndrome died at a nursing home from cardiorespiratory failure with aspiration pne…

general practicegeriatric medicine
VIChospital2024-11-13

Finding into death of James Robert Burns

62y · Male·Pulmonary oedema and aspiration in the setting of Down Syndrome and chronic obst…

James Robert Burns, a 62-year-old man with Down syndrome and COPD, died from pulmonary oedema and aspiration at Sunshine Hospital. He was an NDIS participant residing in spe…

emergency medicinegeneral medicine
NSWhome2017-09-14

Inquest into the death of Lynne BARNETT

70y · Female·Unknown

…d be identified. Toxicology was negative for alcohol, medications, and drugs of abuse. She had a history of COPD and presented to her GP with a cough in September 2016, declining chest X-ray. The coroner could not determ…

general practiceforensic medicinediagnostic
TASmental health2019-01-04

Coroner's Finding: Roberts, Nigel Douglas

55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…

Nigel Douglas Roberts, a 55-year-old man with chronic schizophrenia, COPD, and cardiomyopathy, died from cardio-respiratory arrest due to mixed prescription drug sedation (clozapine…

psychiatryemergency medicinemedicationdiagnosticclozapine
VIChospital2024-03-13

Finding into death of Grethe Larsen

67y · Female·Complications of metastatic lung cancer, in a woman with chronic obstructive pul…

Grethe Larsen, a 67-year-old woman with advanced multiple sclerosis, COPD, and metastatic lung cancer, died from complications of her malignancy. She resided in specialist disabilit…

palliative careemergency medicine
SAhospital2017-11-17

Coroner's Finding: CAMERON George William

76y · Male·pneumonia and exacerbation of chronic obstructive airway disease

… medical condition, and the importance of escalating care when respiratory function deteriorates rapidly in COPD patients.

psychiatrygeneral medicinesalbutamol
VIC2025-04-04

Finding into death of John Stuart Richards

81y · Male·Lung cancer

An 81-year-old man with advanced lung cancer and multiple comorbidities died of natural causes while receiving palliative care in prison. He had documented his wishes for comfort-focused care and was registered on the DN…

palliative caregeneral practice
WAhospital2023-07-25

Inquest into the Death of Frank Kenneth MAJOR

75y · Male·complications of metastatic prostate cancer and end-stage chronic obstructive pu…

Frank Kenneth Major, a 75-year-old prisoner with metastatic prostate cancer and end-stage COPD, died of natural causes in October 2021. The coroner found his overall medical care during incarceration wa…

palliative careoncologysystemenzalutamide
VIChospital2014-09-30

Finding into death of Robert James Barron

64y · Male·lung cancer

Robert James Barron, aged 64, was a psychiatric inpatient at Thomas Embling Hospital, involuntarily detained under the Mental Health Act since 2000 and subject to parole supervision. In December 2012, his physical health…

psychiatrygeneral medicineclozapine
NSWhospital2017-09-07

Inquest into the death of Bruce Thomas

69y · Male·Metastatic non-small cell lung cancer on a background of dilated cardiomyopathy,…

…a custodial sentence, died of metastatic non-small cell lung cancer with concurrent dilated cardiomyopathy, COPD, and hypertension. Lung masses were discovered in May 2015 during admission for fainting episodes. Stage 3 …

oncologycardiology
NThospital2020-07-17

Inquest into the death of Ishmael Nawirridj

51y · Male·Multiple organ failure due to Influenza A pneumonia, in the context of chronic k…

…1-year-old Aboriginal man with complex medical history including myasthenia gravis, chronic kidney disease, COPD, and ischaemic heart disease, died from multiple organ failure due to Influenza A pneumonia while in ICU cu…

intensive carerespiratory medicinemedicationmeropenem
SAhospital2016-02-08

Coroner's Finding: FIDGE Patricia Ann

67y · Female·choking and ischaemic heart disease

…schaemic heart disease. She was admitted with delirium, hypernatremia, and multiple comorbidities including COPD and sleep apnoea. While eating breakfast on day 3 of admission, she aspirated food material that lodged in …

emergency medicinepsychiatryrisperidone

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