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WAcommunity2019-11-15

Inquest into the Suspected Death of Brian Anthony DUFFY

52y · Male·Drowning in Falcon Bay

…intoxicated and agitated following a domestic argument. He was severely limited in mobility and in constant pain despite multiple medications. The coroner found he died by drowning in Falcon Bay, likely walking into shal…

SAhospital2007-09-18

Coroner's Finding: MARKANTONAKIS Stefanos

63y · Male·uncontrolled haemorrhage from ruptured aortic aneurysm

A 63-year-old man presented with sudden back pain on 6 March 2004. Ambulance officers attended twice; on the first visit they did not transport him to hospit…

emergency medicineparamedicinediagnosticcommunicationparacetamol/codeine
VIChome2017-06-20

Finding into death of Finding Ms RF

50y · Female·Potentially fatal multiple drug toxicity (oxycodone, mirtazapine, citalopram, cl…

Ms RF, a 50-year-old woman with epilepsy and chronic pain from a workplace wrist injury, died from potentially fatal multiple drug toxicity involving oxycodone, mirt…

general practiceneurosurgerysystemcommunicationoxycodone
VIChospital2016-08-19

Finding into death of Margaret Smith

91y · Female·Unascertained

…lectroconvulsive therapy (ECT) as a compulsory patient. On 5 March 2015, she developed epigastric and chest pain in the early hours; Dr O. assessed this as likely reflux or angina, prescribed appropriate medications, and…

psychiatrygeriatric medicinediagnosticdelaylithium
SAcommunity2023-01-31

Coroner's Finding: Bromage, Ronald

72y · Male·acute cerebral infarction complicating acute myocardial infarction

…d 72, died from acute cerebral infarction complicating acute myocardial infarction. He presented with chest pain on 22 and 25 February 2016 to his GP, Dr P., who diagnosed costochondritis without performing ECG or tropon…

general practicecardiologydiagnosticdelayparacetamol/codeine
SAhome2014-04-17

Coroner's Finding: KEITH George

80y · Male·gunshot wound to the head

An 80-year-old man with chronic back pain died by self-inflicted gunshot wound to the head on 1 March 2011. Five days before his death, he mentioned …

general practiceorthopaedic surgerydiagnosticcommunicationoxycodone
NT2018-11-26

Inquest into the death of Jeremy aka Lawrence Tunkin

39y · Male·acute myocardial ischaemia, coronary artery thrombosis and coronary artery ather…

…rison custody. On 6 August 2017, he presented to the medical clinic with what prisoners identified as chest pain, but staff interpreted as throat or shoulder complaints. Communication difficulties due to his deafness lik…

emergency medicinecardiologycommunicationdiagnosticadrenaline
SA2019-06-07

Coroner's Finding: AZAPARTI Wyatt William

45y · Male·mixed drug toxicity (methadone and pregabalin) with possible contributing factor…

… and pregabalin, with possible contribution from morbid obesity. He had a history of opioid use and chronic pain from a foot injury. Despite requesting entry to the prison methadone substitution program, he was appropria…

correctional healthpain medicinemethadone
VIChospital2024-05-06

Finding into death of Errol Leslie Solly

67y · Male·Ischaemic heart disease; coronary artery atherosclerosis (stented)

… 67-year-old man with extensive cardiac history presented to the ED with recurrent ischaemic-sounding chest pain. Despite multiple episodes of chest pain during admission, initial ECGs and troponins were normal. Followin…

emergency medicinecardiologydiagnosticcommunicationmorphine
TAShome2022-10-25

Coroner's Finding: Meyer, Glenn Sturley

45y · Male·mixed drug toxicity

Glenn Sturley Meyer, aged 45, died from mixed drug toxicity on 22 August 2019. He had chronic pain, PTSD, depression and anxiety managed with oxycodone and diazepam. He also had obesity and probable obstruc…

general practicepsychiatryoxycodone
TAShospital2017-01-03

Coroner's Finding: Summerfeldt; Ian Patrick

48y · Male·sepsis and renal failure due to perforated gastric ulcer

…chizo-affective disorder presented to West Coast District Hospital on 20 October 2014 with severe abdominal pain radiating to the right shoulder tip, generalised tenderness, and a pain rating of 8/10. Clinical observatio…

emergency medicinegeneral practicediagnosticdelayketorolac
NSWhome2017-09-15

Inquest into the death of Charles Welsford SMITHERS

32y · Male·Presumed cardiac arrhythmia with congenital coronary artery anomaly (absent righ…

… medical history and no regular GP. Months before death, he experienced three episodes of chest or shoulder pain but did not seek medical evaluation. The inquest established that the left coronary circulation was enlarge…

cardiologyforensic medicinediagnostic
VIC2014-09-11

Finding into death of Lloyd Felman

58y · Male·Amitriptyline toxicity

Lloyd Felman, a 58-year-old man with chronic pain, depression, and alcohol use, died from amitriptyline toxicity in July 2008. In the three weeks prior, he p…

psychiatryemergency medicineamitriptyline
QLDhome2014-11-26

Wallrock, William Charles - Non-inquest findings

22y · Male·mixed drug toxicity due to methadone, codeine, and morphine (metabolite), compou…

… tooth extraction. He was initially appropriately advised to use paracetamol and ibuprofen. When inadequate pain relief prompted him to seek further medical care, Dr T. prescribed Mersyndol Forte (appropriate) and suppli…

dentistrygeneral practicemedicationcommunicationmethadone
VIChospital2013-06-17

Finding into death of Trevor Edward Hammond

72y · Male·ischaemic heart disease secondary to coronary artery disease

A 72-year-old man with hypercholesterolaemia and obesity presented to the ED with chest pain and atrial fibrillation. Initial ECG showed no acute changes. Clinicians pursued a pulmonary embolus diagno…

emergency medicinecardiologydiagnosticdelaydigoxin
NSW2021-11-30

Inquest into the death of Elias MELHEM

49y · Male·atherosclerotic and hypertensive cardiovascular disease, with type 2 diabetes me…

…rtensive cardiovascular disease with contributing type 2 diabetes. On 8 December 2019, he experienced chest pain at work but reported feeling better after resting. He did not disclose this symptom to Justice Health staff…

cardiologynephrologycommunicationinsulin
NSW2025-03-24

Inquest into the death of HC

64y · Female·Unascertained

A 64-year-old woman with chronic pain from multiple joint replacements, significant depression following her daughter's death in 2006, and long-s…

VIChospital2012-04-13

Finding into death of Joel Aaron Frigo

30y · Male·Haemopericardium caused by ruptured dissecting thoracic aortic aneurysm

Joel Frigo, 30-year-old with Marfan's syndrome, presented to a regional hospital with chest pain and was diagnosed with a chest infection/pleurisy. He died from a ruptured dissecting thoracic aortic aneur…

emergency medicinecardiologydiagnosticcommunicationatenolol
SAhospital2018-10-10

Coroner's Finding: ATKINS Stephen Robert

53y · Male·fentanyl and oxycodone toxicity

…thy. Over three days, escalating opioid doses were prescribed in combination without adequate monitoring or pain specialist review. Critical failures included: failure to escalate care via mandated RaDAR protocols despit…

neurologyemergency medicinediagnosticmedicationfentanyl
VIC2018-04-16

Finding into death of Jason Joseph Mirko Ljepojevic

30y · Male·Haemopericardium due to dissecting aortic aneurysm secondary to bicuspid aortic …

A 30-year-old man in prison presented with severe central chest pain radiating to neck and back after gym exercise. A GP conducted physical examination, ECG, and diagnosed musc…

general practiceemergency medicineparacetamol

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