Coronial
WAhospital2013

Inquest into the Death of Zappacosta, Palmerino

86y · Male·Sepsis associated with a pericolic abscess, complicated by terminal large intest…

An 86-year-old life-sentenced prisoner died from sepsis associated with a pericolic abscess complicated by terminal gastrointestinal haemorrhage. He had extensive comorbidities including bilateral amputations, cardiac fa…

emergency medicinegeneral medicinevenlafaxine
VIChospital2016-07-28

Finding into death of Dianne Kaye Quinlan

51y · Female·Pulmonary thromboembolism in the setting of morbid obesity

Ms Quinlan, a 51-year-old woman with morbid obesity (BMI 74.2), depression, bipolar disorder and recent diabetes diagnosis, died from pulmonary thromboembolism while an involuntary psychiatric inpatient. She presented wi…

psychiatrygeneral medicinediagnosticcommunicationrisperidone
QLDhospital2018-07-30

Khazaei, Hamid

24y · Male·Hypoxic-ischaemic encephalopathy, due to or as a consequence of cardiac arrest, …

Hamid Khazaei, an Iranian asylum seeker aged 24, died on 5 September 2014 after contracting a leg infection (Chromobacterium violaceum) on Manus Island while in immigration detention. His death was preventable and result…

emergency medicineinfectious diseasesdiagnosticcommunicationceftriaxone
QLDhospital2018-05-11

Orton, David - Non-inquest findings

41y · Male·Cerebral hypoxia and bronchopneumonia; contributing factors: toxic megacolon, ce…

David Orton, a 41-year-old man with cerebral palsy, intellectual disability, and severe kyphoscoliosis, died from cerebral hypoxia and bronchopneumonia complicated by toxic megacolon and Salmonella infection. Over 18 mon…

general medicinegastroenterologydiagnosticcommunicationmovical
QLDhospital2023-03-13

Timms, Peter John

71y · Male·Acute myeloid leukaemia due to transformation from chronic myelomonocytic leukae…

Peter Timms, a 71-year-old prisoner with multiple comorbidities, died from acute myeloid leukaemia (AML) transformed from chronic myelomonocytic leukaemia. He made over 40 health service requests while incarcerated, incl…

haematologypalliative caredelaydiagnosticoral antibiotics
NSWhospital2019-02-07

Inquest into the death of Sharon Bell

53y · Female·cardiorespiratory arrest in a person with blunt force head injury, end-stage liv…

Sharon Bell was found dead in her hallway on 25 May 2013 aged 53. She had end-stage liver disease with hepatic encephalopathy, had suffered recent blunt force head injuries of unclear origin, and had high blood methadone…

emergency medicineforensic medicinediagnosticcommunicationmethadone
QLDhospital2025-08-11

Inquest into the death of John Reginald Wright

79y · Male·Complications of peripheral vascular disease with Type 2 Diabetes Mellitus, atri…

John Reginald Wright, a 79-year-old remand prisoner, died from complications of peripheral vascular disease with diabetes, atrial fibrillation, cardiomyopathy and delirium. He was transferred to Princess Alexandra Hospit…

vascular surgerygeneral medicineglicazide
NSW2024-03-13

Inquest into the death of O A

44y · Male·multiple injuries from fall from cliff

A 44-year-old man with familial Mediterranean fever (FMF) and bipolar affective disorder with drug-induced psychosis died following a fall from a cliff at Vaucluse during a police rescue operation. He had been managing s…

rheumatologyallergy and immunologycommunicationsystemoxycodone
TAShospital2015-09-07

Coroner's Finding: Weir, Mary

80y · Female·subdural haematoma due to closed head injury sustained in a fall from bed in hos…

An 80-year-old woman with chronic heart failure admitted to hospital fell from bed and hit her head. Although nursing staff were concerned about a possible head injury, the House Medical Officer incorrectly concluded no …

emergency medicinegeneral medicinediagnosticmedicationaspirin
WAhome2016-11-22

Inquest into the Death of Maria Carmel NICEFORO

75y · Female·organ failure due to sepsis, likely from infected pressure sores, in the context…

Maria Carmel Niceforo, a 75-year-old woman with poorly controlled diabetes and ischaemic heart disease, died from septic shock secondary to extensive infected sacral pressure wounds. She received home care through KinCar…

general practiceemergency medicinecommunicationsystem
VICaged care2023-03-22

Finding into death of Margaret Alice Cook

88y · Female·Complications of a stage 3 sacral pressure ulcer in a woman with dementia

Margaret Alice Cook, an 88-year-old woman with end-stage dementia, died from complications of a stage 3 sacral pressure ulcer at a palliative care unit. She had resided at Crofton House Supported Residential Services (SR…

geriatric medicinegeneral practicesystemcommunicationflucloxacillin
QLDaged care2024-10-22

Non-inquest findings into the death of MH, an aged care resident

98y · Female·Sepsis due to sacral pressure ulcer complicated by osteomyelitis against a backg…

A 98-year-old woman with dementia and multiple comorbidities died from sepsis secondary to a sacral pressure ulcer that progressed to osteomyelitis while in residential aged care. The coroner identified systemic clinical…

geriatric medicinegeneral practicediagnosticsystemwarfarin
VIChospital2025-10-28

Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …

Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarce…

infectious diseasesvascular surgerydiagnosticsystemantibiotics
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
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…

emergency medicineintensive carediagnosticproceduralhydromorphone
WAhospital2017-08-23

Inquest into the Death of Marjorie Joy JARICK

54y · Female·Opioid toxicity (predominantly fentanyl)

54-year-old woman with diabetes, obesity, and multiple opioid allergies underwent groin surgery at a private hospital. Anaesthetist Dr Y. prescribed a 75mcg/hr fentanyl patch post-operatively for chronic pain management …

anaesthesiasurgerymedicationcommunicationfentanyl
QLDhospital2024-11-20

Non-inquest findings into the death of Mr W

82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis

An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …

general medicinegeriatric medicinediagnosticcommunicationendone 2.5mg
VIChospital2020-03-26

Finding into death of Matthew John George

45y · Male·Global cerebral hypoxia following cardio-respiratory collapse due to anaphylaxis…

A 45-year-old man with poorly controlled diabetes, ischaemic heart disease, and recurrent lower limb infections died from anaphylaxis to intravenously administered flucloxacillin. He presented with sepsis secondary to a …

general medicineinfectious diseasescommunicationdiagnosticflucloxacillin
WApolice custody2017-03-31

Inquest into the Death of Maureen MANDIJARRA

44y · Female·unascertained (consistent with Streptococcus dysgalactiae and Staphylococcus aur…

Maureen Mandijarra, a 44-year-old Aboriginal woman with poorly controlled diabetes and recurrent skin infections, was arrested at Male Oval on 29 November 2012 for street drinking under a zero-tolerance police approach. …

emergency medicineinfectious diseasesdiagnosticcommunicationalcohol

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