Coronial
NThospital2015-02-19

Inquest into the death of Desmond Tilmouth

50y · Male·myocardial infarction caused by coronary atherosclerosis

Desmond Jambajimba Tilmouth, a 50-year-old Aboriginal man, died of myocardial infarction from severe coronary atherosclerosis complicated by end-stage renal disease and an incarcerated strangulated umbilical hernia. He d…

surgeryanaesthesiaoxycodone
SAhospital2022-06-10

Coroner's Finding: Bertram, Kerry Anne

42y · Female·multiorgan failure complicating hyperthermia and metabolic acidosis following su…

A 42-year-old woman with long-standing depression, substance use issues, and multiple mental health presentations died from multi-organ failure following ingestion of caustic soda. She was found unresponsive at home on 1…

intensive carepsychiatryalcohol
SAhospital2021-11-25

Coroner's Finding: Cannell, Peter Tasman

48y · Male·Multi-organ failure from acute gastrointestinal haemorrhage associated with oeso…

Peter Tasman Cannell, aged 48, died in Flinders Medical Centre from multi-organ failure due to acute gastrointestinal haemorrhage from oesophageal varices on a background of liver cirrhosis. He had a medical history of h…

gastroenterologyhepatology
QLDhospital2019-12-05

Burrows, Frank Leslie

58y · Male·Haemophagocytic lymphohistiocytosis, due to or as a consequence of T-cell lympho…

Frank Burrows, a 58-year-old male prisoner, died from Haemophagocytic Lymphohistiocytosis (HLH) secondary to T-cell lymphoma. He presented with non-specific symptoms (fever, sweats, diarrhoea) and was initially discharge…

general medicinehaematologydexamethasone
VIChospital2008-03-20

Finding into death of Julie Stephens

54y · Female·sepsis

Ms Julie Stephens, aged 54, was admitted to Frankston Hospital on 5 December 2008 with a chest infection and multiple comorbidities including cardiac failure, respiratory failure, and obesity. She deteriorated with septi…

intensive carerespiratory medicinemedicationsystemmorphine
SAhospital2020-06-18

Coroner's Finding: THOMPSON Wayne Robert McInnes

33y · Male·Multi-organ failure due to sepsis on a background of severe ischaemic cardiomyop…

Wayne Robert McInnes Thompson, aged 33, died from multi-organ failure due to sepsis complicated by severe ischaemic cardiomyopathy. He had a complex medical history including viral myocarditis, previous intestinal resect…

cardiologyintensive carewarfarin
QLDhospital2023-07-05

Conlon, Edgar

75y · Male·End-stage renal disease, with hypertension, ischaemic heart disease, and diabete…

…idities including heart failure, diabetes, hypertension, and ischaemic heart disease. During routine haemodialysis on 12 July 2021, he suffered acute hypotension and loss of consciousness. Subsequent attempts at dialysis

nephrologycardiologyaspirin
TAShospital2021-11-29

Coroner's Finding: Bennett, Anthony George

77y · Male·shock due to bowel ischaemia following massive blood loss due to bleeding of the…

Anthony George Bennett, a 77-year-old man with significant comorbidities including ischaemic heart disease, atrial fibrillation, peripheral vascular disease, and end-stage kidney disease, died from shock due to bowel isc…

vascular surgerycardiology
WAhospital2014-12-30

Inquest into the Death of Gheorghe Gruici

71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…

Gheorghe Gruici, a 71-year-old life-sentenced prisoner, died of organ failure from chronic renal failure, infective endocarditis, and chest infection. Over 15 years in custody, he developed multiple comorbidities includi…

general medicinenephrologyomeprazole
VIChospital2011-09-19

Finding into death of Stephen Johnson

47y · Male·Multiple organ failure due to Aeromonas Sobria sepsis in a man with cirrhosis

Stephen Johnson, a 47-year-old teacher, died from sepsis caused by Aeromonas Sobria bacteria acquired through a cut hand exposure to contaminated farm water. He presented to hospital with non-specific symptoms and elevat…

emergency medicineinfectious diseasesdelay
TAShospital2021-08-20

Coroner's Finding: LA

67y · Male·acute gastrointestinal haemorrhage complicating peptic ulcer of the duodenum wit…

A 67-year-old man died from acute gastrointestinal haemorrhage from a duodenal ulcer following complex post-operative complications from laparoscopic Hartmann's procedure for diverticulitis. Key clinical lessons: (1) Ear…

general surgeryintensive carediagnosticmedicationrabeprazole
TAShome2022-07-15

Coroner's Finding: Summers, Nicholas John

41y · Male·heart failure related to exsanguination due to traumatic rupture of an arteriove…

Nicholas Summers, a 41-year-old kidney transplant recipient, died from traumatic rupture of an arteriovenous fistula with massive hemorrhage on 16 February 2016. He had returned to Tasmania under nephrologist Dr M.'s car…

nephrologyvascular surgerysystemdelay
VIChospital2021-12-06

Finding into death of Ingeburg Hildegard Muller

85y · Female·Staphylococcus bacteremia complicating multiple injuries sustained in a motor ve…

An 85-year-old woman sustained multiple serious injuries (bilateral rib and pelvic fractures, thoracic spine fractures) in a motor vehicle collision on 20 June 2018. She was treated with ICU admission, induced coma, and …

emergency medicineintensive caresystemantibiotics
TAScommunity2024-01-30

Coroner's Finding: Ryan, Robert John

35y · Male·Multiple organ failure—cause not determined to requisite standard

Robert John Ryan, a 35-year-old senior stockman, collapsed suddenly on 7 January 2015 at a farm gate near his workplace at Malahide in Tasmania, while driving his work utility during a normal workday. He presented with s…

toxicologyintensive carediagnosticdelayparoxetine
NSWhospital2015-06-16

Inquest into the death of Sean WAYGOOD

47y · Male·acute renal failure caused by bilateral ureteral obstruction due to metastatic c…

Sean Waygood, an Extreme High Security prisoner, died from acute renal failure caused by metastatic colorectal cancer. He presented with abdominal pain, constipation, and blood per rectum in March 2011 but received subop…

general practiceoncologydiagnostictramadol
VIChospital2010-03-15

Finding into death of Deborah Margaret Ricklefs

29y · Female·Invasive aspergillosis

A 29-year-old registered nurse with systemic lupus erythematosus (SLE) died from invasive aspergillosis. Dr G. prescribed lamotrigine 100 mg daily (double the recommended initial dose of 50 mg) on first consultation with…

addiction medicinegeneral practicemedicationdiagnosticlamotrigine
QLDhospital2010-05-07

Cramb, Fay - aka Valmae Beck

64y · Female·Haemorrhage into atheromatous plaque, due to coronary atherosclerosis

Fay Cramb, a 64-year-old woman imprisoned for 20+ years, died on 27 May 2008 from coronary atherosclerosis with haemorrhage into atheromatous plaque. She suffered an acute cardiac event on 5 May 2008 requiring emergency …

cardiologyintensive caresystem
ACThospital2024-09-16

Inquest Into The Death Of Sharyn Kaine

73y · Female·Multi organ failure due to adhesions related bowel perforation (surgically treat…

Sharyn Kaine, a 73-year-old woman, died from multi-organ failure due to adhesions-related bowel perforation and paracetamol-induced liver failure. She was prescribed intravenous paracetamol 1g four times daily post-opera…

general surgeryanaesthesiamedicationtranscriptionparacetamol
VIChospital2022-02-22

Finding into death of Matthew Lee Dongelmans

30y · Male·Complications of methylamphetamine toxicity

Matthew Dongelmans, aged 30, died from complications of methylamphetamine toxicity after being arrested for breaching a family violence intervention order. He consumed methylamphetamine prior to arrest, likely in panic w…

emergency medicineintensive caredelaysystemmethamphetamine
VIChospital2023-02-22

Finding into death of Christine Ann Stephen

67y · Female·Intra-abdominal sepsis complicating an anastomotic leak following elective surge…

A 67-year-old woman died from intra-abdominal sepsis following an anastomotic leak from elective colorectal surgery to repair a vesico-colic fistula. The initial surgery on 1 November 2017 was appropriately performed, an…

colorectal surgeryintensive carecommunicationdelaynoradrenaline

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