Coronial
SAhospital2017-08-25

Coroner's Finding: WARNE Garry Robert

58y · Male·pneumonia on a background of adenocarcinoma of the lung stage 4, ischaemic heart…

58-year-old male prisoner died from pneumonia complicated by stage 4 lung adenocarcinoma, ischaemic heart disease, and chronic emphysema. He presented with critical leg ischaemia requiring femoral endarterectomy, develop…

vascular surgerycardiology
QLDhospital2009-08-13

Duggan, David John

60y · Male·Hypertensive heart disease with chronic fatty liver as other significant conditi…

…mic issues: the inappropriate admission of an acute pain patient to a geriatric-focused hospital, delays in MRI transmission to RBH affecting clinical decision-making, inadequate pain management documentation and protoc…

emergency medicinegeneral medicinesystemcommunicationoxycodone
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
TAShospital2022-03-18

Coroner's Finding: Collis, Mary

73y · Female·pulmonary embolus

Mary Collis, a 73-year-old woman with bipolar disorder and type 2 diabetes, died from pulmonary embolus whilst an inpatient at Launceston General Hospital on 15 June 2020. She was admitted after becoming unconscious at h…

intensive carepsychiatry
VICcommunity2014-03-19

Finding into death of Darren Brett Kingma

29y · Male·Bronchopneumonia complicating neck injuries sustained in a fall, with Coffin-Low…

…without first-hand information from the initial finder, could not detect the spinal injury. At hospital, CT scan interpretation missed the unstable fracture, leading to premature removal of the cervical collar. Clinician…

emergency medicineradiologydiagnosticcommunicationclonazepam
QLDhospital2018-01-24

McLaughlin, Mark Ian

55y · Male·Glioblastoma multiforme

Mark Ian McLaughlin, a 55-year-old man in custody, presented with haematuria and neurological symptoms and was found to have a grade 4 glioblastoma multiforme on imaging and histopathology. He underwent appropriate neuro…

emergency medicineneurosurgery
VIChospital2025-04-30

Finding into death of Margaret Ann Day

66y · Female·Ischaemic brainstem stroke

Margaret Ann Day, a 66-year-old Specialist Disability Accommodation resident with undifferentiated hereditary ataxia, intellectual disability, and dysphagia, presented to the Emergency Department on 26 November 2024 with…

neurologyemergency medicinelevetiracetam
SA2023-12-22

Coroner's Finding: Schuster, Gavin Shawn

45y · Male·Liver failure due to metastatic hepatocellular carcinoma

A 45-year-old male prisoner died from liver failure due to metastatic hepatocellular carcinoma. He had been prescribed cyproterone (Androcur) for 20+ years as an anti-libidinal agent, with regular blood tests monitoring …

psychiatryoncologycyproterone
TAShospital2025-04-23

Coroner's Finding: Dow, Vicki Elizabeth

69y · Female·Multiple organ failure due to secondary haemochromatosis (transfusion-associated…

Mrs Vicki Dow, 69, died from multiple organ failure secondary to iron overload (transfusion-associated haemochromatosis) from treatment of myelodysplastic syndrome. She had declined iron chelation therapy for 19 months d…

haematologyemergency medicinecommunicationdiagnosticiron chelation therapy
VIChospital2019-07-16

Finding into death of Baby J

1y · Unknown·Hypoxic ischaemic encephalopathy post cardiac arrest due to nicotine toxicity

Baby J, an 18-month-old child, ingested liquid nicotine that had been left unattended on a dining table. The concentrated nicotine product was illegal in Australia, imported from the USA for use in e-cigarettes. Within m…

intensive careemergency medicineliquid nicotine
QLDcommunityPodcast2020-06-26

Nyholt, Nicole Sonia and Clark, Margaret Louisa

Female·Burns due to gas explosion due to motor vehicle collision with building

A 60-year-old man with a long-standing history of seizures experienced an epileptic seizure while driving and lost control of his vehicle. It collided with an LPG gas cylinder outside a café, triggering an explosion that…

emergency medicineneurologycommunicationsystem
SAhospital2022-03-29

Coroner's Finding: Foster, Clive Anthony

76y · Male·end-stage renal failure

A 76-year-old man died of end-stage renal failure while imprisoned. He had pre-existing hypertension, diabetes, and stage 3 chronic kidney disease. During his final year in custody, he experienced acute kidney injury sup…

general medicinenephrology
VIChospital2015-07-29

Finding into death of Beatrix Dammers

56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy

…eurologically at 10:30pm with new visual field loss, heparin was escalated rather than stopped and urgent rescanning arranged. She had a large intracranial haemorrhage, likely secondary to anticoagulation, and died the n…

emergency medicineneurologydiagnosticmedicationenoxaparin
QLDhospital2025-05-26

Findings into the death of Trevor Charles Stone

57y · Male·Metastatic lung adenocarcinoma (stage IVA non-small cell lung cancer)

Trevor Charles Stone, a 57-year-old First Nations man imprisoned for sexual offences, died from metastatic lung adenocarcinoma with contributing comorbidities (diabetes, hypertension, dyslipidaemia, ischaemic heart disea…

oncologypalliative carecarboplatin
SAhospital2013-04-08

Coroner's Finding: MAY Terrill Anthony

69y · Male·subarachnoid haemorrhage with contributing cardiomegaly

…ts were not communicated to ED staff, and the patient was discharged with an unspecified diagnosis after an MRI that could not exclude aneurysm. A neurosurgery outpatient appointment was scheduled 2 weeks later but the …

emergency medicineneurosurgerydiagnosticcommunicationperindopril
WAhospital2013

Inquest into the Death of Davies, Adriana Elise

46y · Female·brain swelling and dural venous thrombosis in association with low grade glioma …

Dr D., a 46-year-old medical practitioner, died from brain swelling and dural venous thrombosis associated with a low-grade glioma. She presented to Albany Hospital on 10 October 2005 with a severe, different headache ch…

general practiceneurosurgerydiagnosticcommunicationprochlorperazine
NThospital2003-04-10

Inquest into the death of Eric Gaykamangu

37y · Male·primary intracerebral haemorrhage, contributed to by acute alcohol intoxication

Eric Gaykamangu, a 37-year-old Aboriginal man, died of primary intracerebral haemorrhage whilst in hospital ICU, nine days after initial presentation. He was found intoxicated outside Centrelink on 7 December 2001 with m…

neurosurgeryemergency medicinealcohol
NThospital2016-04-22

Inquest into the death of Bundy Namarnyilk

56y · Male·Acute bronchopneumonia secondary to locally advanced, poorly differentiated squa…

A 56-year-old Aboriginal man died in custody from bronchopneumonia secondary to metastatic hypopharyngeal squamous cell carcinoma. He first presented with sore throat in February 2014 and was referred to ENT clinic in Ap…

ENT surgeryoncology
SAhospital2020-07-14

Coroner's Finding: DUSZYNSKI Steve Stan Peter

66y · Male·Bronchopneumonia and influenza A complicating cardiac and renal failure associat…

A 66-year-old man with cryoglobulinaemic vasculitis secondary to non-Hodgkin's lymphoma died from bronchopneumonia and influenza A complicating cardiac and renal failure. He developed delirium, agitation and paranoia dur…

nephrologyhaematologydelayolanzapine
WA2026-03-09

Inquest into the Death of Russell Graham PENNY

56y · Male·complications of viral hepatitis related advanced-chronic liver disease

Russell Graham Penny, 56, a Noongar man, died from advanced liver disease with hepatocellular carcinoma while in prison custody. With chronic hepatitis C from intravenous drug use, Russell had developed cirrhosis and was…

correctional healthgeneral medicinesystemcommunication

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