Coronial
WAhome2015-06-18

Inquest into the Death of MKP

15y · Female·Seizure Disorder in association with Long Standing Hypoxic Ischaemic Encephalopa…

… in her foster home on 26 December 2011. She had progressive respiratory compromise with obstructive sleep apnoea and desaturations noted in the months before death. Her paediatrician had identified the need for a multid…

neurologypaediatricsdelaydiazepam
NT2016-06-29

Inquest into the death of Peter Fittock

61y · Male·self-inflicted hanging

…d a veterinary nursing qualification. The coroner found his chronic conditions (atrial fibrillation, sleep apnoea) were well-managed, with recent INR levels appropriate. Evidence suggests he was stressed about the possib…

warfarin
VIChospital2019-10-29

Finding into death of Ms C

49y · Female·hypoxic ischaemic encephalopathy complicating cardiac arrest due to pulmonary th…

A 49-year-old woman with morbid obesity, obstructive sleep apnoea, and psychiatric history was admitted following deliberate medication overdose. She was intubated, managed…

emergency medicineintensive caresystemheparin
NSWhome2023-09-25

Inquest into the death of Wayne Mullin

64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…

…ical lessons include: oxycodone and benzodiazepines are dangerous in patients with severe asthma and sleep apnoea; medication compliance was a concern (missed dupilumab doses); and monitoring gaps existed during the COVI…

general practicerespiratory medicinemedicationcommunicationoxycodone
WAprison2021-09-06

Inquest into the Death of Marshall Ruben EDGILL

38y · Male·combined effects of acute-on-chronic respiratory disease and cardiomegaly

… custody from acute-on-chronic respiratory disease and cardiomegaly. He had longstanding obstructive sleep apnoea (OSA), obesity, asthma, and hypertension. Critical missed opportunities included: failure to formally diag…

respiratory medicinecardiologydiagnosticdelay
VIChospital2024-08-14

Finding into death of Gayle Dianne Ireland

63y · Female·Sepsis with multiorgan failure in the setting of limb cellulitis complicating a …

A 63-year-old woman with multiple comorbidities (obesity, chronic lung disease, obstructive sleep apnoea, prior cerebrovascular disease with hemiparesis) sustained a 4cm laceration to her right shin from a motor…

emergency medicineintensive carediagnosticdelayceftriaxone
SAaged care2024-05-22

Coroner's Finding: Donato, Anthony

85y · Male·blunt craniocerebral trauma following a fall

…rebral trauma following an unwitnessed fall at an aged care facility. He had dementia, hypertension, sleep apnoea, and previous falls. He was assessed as medium fall risk but fell from bed, sustaining a multicompartmenta…

geriatric medicineemergency medicine
TAShome2023-07-24

Coroner's Finding: QD de-identified

45y · Female·combined drug (tapentadol, nortriptyline, venlafaxine, codeine, oxycodone, queti…

QD, a 45-year-old woman with significant comorbidities including obesity, obstructive sleep apnoea, COPD, depression, and substance abuse history, died from mixed drug and alcohol intoxication. Toxicology …

general practicepsychiatrydelaysystemtapentadol
VIChospital2012-07-03

Finding into death of Pruseyus Lily Sharp

0y · Female·Hypoxic brain injury secondary to pneumonia and pulmonary haemorrhage

…condary to pneumonia and pulmonary haemorrhage caused by picornavirus infection. She presented with severe apnoea and minimal preceding symptoms—notably no fever, cough, or wheeze—making early recognition challenging. He…

paediatricsneonatologydelay
NThome2010-10-29

Inquest into the death of Kristelle Ruby Mulladad aka Oliver

16y · Female·obstructed breathing and heart arrhythmia secondary to severe obstructive sleep …

A 16-year-old Aboriginal girl with severe obstructive sleep apnoea died unexpectedly in her home one week before scheduled surgery. She had been symptomatic since age 13, bu…

ENT surgerygeneral practicediagnosticcommunication
VIChospital2020-07-14

Finding into death of Gerard Guy Vaz

61y · Male·Undetermined

Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with ps…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
NSWhospital2021-12-02

Inquest into the death of Joshua Szczudlo

33y · Male·Fatal cardiac arrhythmia, secondary to acute kidney injury

…yperkalaemia. Pre-operative assessment identified significant risks (obesity, hypertension, probable sleep apnoea) but surgery proceeded with appropriate anaesthetic management. Post-operative care occurred on a general …

orthopaedic surgeryanaesthesiasystemcommunicationmorphine
TASaged care2021-11-04

Coroner's Finding: Rosendale, Dwayne Edward

36y · Male·Complications of morbid obesity, including cardiac enlargement, aspiration of ga…

…ical oversight. He died two days later from cardiac enlargement, aspiration of gastric contents, and sleep apnoea, likely precipitated by alcohol and clozapine (found at therapeutic levels despite not being prescribed). …

psychiatrygeneral medicinesystemdelayzuclopenthixol
TAShome2022-11-11

Coroner's Finding: KL

31y · Male·global hypoxic brain injury secondary to positional asphyxia following an epilep…

…elated to medication non-compliance and sleep deprivation), morbid obesity (BMI 39), and undiagnosed sleep apnoea. This case highlights the importance of seizure management compliance, the risks of unwitnessed seizures a…

neurologyemergency medicineanti-epileptic medications
VIChome2024-01-24

Finding into death of HM Q

5y · Unknown·Aspiration pneumonia complicating a gastrointestinal illness in a child with cer…

HMQ was a 5-year-old with severe cerebral palsy (GMFCS level 5), genetic disability (CACNA1A deletion), intractable epilepsy, and aspiration risk who died from aspiration pneumonia following a gastrointestinal illness. H…

paediatricsneurology
NSW2025-05-02

Inquest into the death of Emmett Brown

25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…

…an, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvidal opioid replacement therapy program in Aug…

correctional healthaddiction medicinediagnosticsystemmethadone
WAhospital2023-11-29

Inquest into the Death of Samuel Edward ASHBY

46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…

…duced sedation and hypersalivation increase aspiration risk, particularly with untreated obstructive sleep apnoea; (4) support for patients with cognitive impairment to maintain medical devices (CPAP) is essential. Clini…

psychiatrygeneral medicinediagnosticsystemclozapine
NSWhospital2022-02-01

Inquest into the death of Ivan CHRISTOV

70y · Male·complications of chronic obstructive pulmonary disease and ischaemic heart disea…

A 70-year-old man with end-stage COPD, ischaemic heart disease, and obstructive sleep apnoea collapsed in his prison cell and was transferred to hospital in respiratory distress. Despite having docum…

emergency medicinerespiratory medicinecommunicationdelay
NSWhospital2020-09-25

Inquest into the death of Gregory MASTERS

52y · Male·Polypharmacy overdose of amitriptyline and doxylamine in the context of underlyi…

…2-year-old man with chronic facial pain, depression, obesity, cardiovascular disease and obstructive sleep apnoea died following restraint in ICU. He had ingested a polypharmacy overdose of amitriptyline and doxylamine o…

intensive carepsychiatryamitriptyline
QLDmental health2006-02-03

Muckan, David Jones

49y · Male·Obstructive sleep apnoea, contributed to by the sedating effects of therapeutic …

… man with schizophrenia, was admitted to a psychiatric unit in April 1998 with suspected obstructive sleep apnoea (OSA). He was sedated with benzodiazepines (Midazolam, Diazepam) and other psychotropic drugs despite know…

psychiatryrespiratory medicinemedicationmonitoringthioridazine

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