Coronial — Australian Coroners Findings

100 results for “previous heart failure”

SAcommunity2009-03-30

Coroner's Finding: DALLING Brian Terrance and SALOTTI Jack William and GRZYWACZ Richard John and SOBEY Brian Leslie

Male·acute myocardial infarction due to coronary artery disease (all four); specific …

…al practitioners with symptoms suggestive of acute coronary syndrome but were not identified as such. Key failures included: failure to obtain or act on previous abnormal ECGs indicating prior myocardial infarction; ina…

general practiceemergency medicinediagnosticcommunicationaspirin

WAcommunity2019-11-13

Inquest into the Suspected Death of Joseph Wellard HIGGS

81y · Male·Unable to determine - likely dehydration and exposure in remote bushland terrain…

… had cognitive decline with short-term memory loss, difficulty walking due to hip surgery complications, a heart condition managed with a pacemaker, and hearing loss. His vehicle was found abandoned with mechanical faul…

QLDcommunity2016-12-21

Capps, Ruth

75y · Female·multiple injuries due to or as a consequence of motor vehicle collision

…tions including diabetes, sleep apnoea, chronic back pain, osteoarthritis, and recurrent falls. Despite a previous licence cancellation in 2012 due to poor mobility and slow reaction times—supported by hospital consultan…

general practiceoccupational therapydiagnosticcommunicationnitrazepam

WAhospital2023-01-11

Inquest into the Death of Colin Albert WINTER

71y · Male·End-stage chronic obstructive pulmonary disease and atherosclerotic heart diseas…

Colin Albert Winter, a 71-year-old prisoner who died from end-stage COPD and atherosclerotic heart disease, received comprehensive medical care during 33 years of incarceration at Casuarina Prison. Key cli…

respiratory medicinecardiologycommunicationsystem

WAmental health2018-09-19

Inquest into the Death of Wlodzimierz DUDEK

69y · Male·bronchopneumonia and hypoxic brain injury following aspiration of food (choking)

…he death was accidental and supervision was reasonable, as choking was not identified as a risk despite a previous episode of dysphagia documented four months earlier that had apparently resolved. The key clinical lesson…

psychiatryemergency medicinecommunicationsystem

WAprison- 20 March 2014

Inquest into the Death of Anthony Nigel AXTELL

38y · Male·Heart failure in a man with dilated cardiomyopathy and focal severe coronary art…

Anthony Axtell, a 38-year-old man with severe dilated cardiomyopathy from amphetamine use, died of heart failure while in prison custody. Initially treated successfully in 2002 with recovery to normal cardiac fu…

cardiologycardiothoracic surgerymedicationsystemamphetamine

VIChospital2014-11-17

Finding into death of Kam Wah Koh

84y · Male·Pneumonia complicating fractured cervical spine in the setting of fall

An 84-year-old man died from pneumonia and Type 2 respiratory failure nine days after sustaining a severe cervical spine fracture from a fall on a bus. Following the acute tra…

trauma surgeryorthopaedic surgerydexamethasone

VICaged care2019-08-23

Finding into death of John Reimers

63y · Male·complications of an inverted positional event (asphyxia from airway occlusion)

A 63-year-old man with previous stroke and left-sided paralysis fell headfirst into his bedside drawer while attempting to open it from h…

geriatric medicineemergency medicinediagnosticcommunicationduloxetine

WAhospital2024-09-24

Inquest into the death of Raymond Sydney CHEEK

89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…

…ncluding insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarina Prison was generally appropriate, there was one medication error: an 18-…

emergency medicineendocrinologymedicationsystemryzodeg insulin

SAhospital2000-05-12

Coroner's Finding: COPPING Leslie Walter

84y · Male·severe head injuries (fracture of skull on right side, subarachnoid haemorrhage,…

An 84-year-old man with severe respiratory disease, cardiac failure, poor vision and confusion fell from a first-floor hospital window, sustaining fatal head injuries. The c…

emergency medicinegeneral practicesystemcommunication

NSWmental health2022-05-06

Inquest into the death of Diane EASTCOTT

71y · Female·ischaemic cardiovascular disease

… where atrial fibrillation was diagnosed. A critical medication error occurred: verapamil (continued from previous prescription) and metoprolol were prescribed concurrently without clinical indication—a contraindicated c…

emergency medicinecardiologymedicationcommunicationmetoprolol

VIChospital2020-01-31

Finding into death of Brett Maybus

60y · Male·Haemorrhage complicating a left robotic upper mediastinal lymph node clearance i…

…arcinoma. The coroner found the fatal bleed was likely caused by rupture of a blood vessel compromised by previous high-dose radiotherapy to that region. The critical clinical lesson concerns informed consent: while the …

cardiothoracic surgeryoncologycommunicationsystem

SAhospital2002-02-28

Coroner's Finding: GALEA Lesley Anne

30y · Female·respiratory failure related to bronchopneumonia following cerebral anoxia due to…

A 30-year-old woman with a previous caesarean section attempted a trial of vaginal delivery. She received Syntocinon augmentation at 6:45 AM …

obstetricsanaesthesiadiagnosticcommunicationoxytocin

VIChospital2016-05-19

Finding into death of Josip Dobrovoljski

62y · Male·Global cerebral ischaemia secondary to intra-operative hypotension following the…

…ery bypass surgery, which was inadequately documented and not communicated to the ablation team. Critical failures included: incomplete anaesthetic charting of the initial protamine reaction, absent handover communicati…

anaesthesiacardiologydocumentationcommunicationprotamine

NThospital2014-05-15

Inquest into the death of Eric Lewis Wobona

55y · Male·Cardiac hypertrophy with significant conditions contributing: coronary artery at…

…ar risk factors including congestive cardiomyopathy, coronary artery disease, hypertension, diabetes, and previous amputation, died of acute heart failure from cardiac hypertrophy with coronary artery atherosclerosis. He…

cardiologyemergency medicineaspirin

WAhospital2022-10-05

Inquest into the Death of David Arthur RICE

75y · Male·acute bronchopneumonia in a man with comorbidities

…y ill register and received comprehensive medical care that exceeded community standards. However, system failures prevented consideration of early release via Royal Prerogative of Mercy: briefing notes required by poli…

general medicinecardiologysystemapixaban

TASaged care2024-10-22

Coroner's Finding: Whish-Wilson, Leslie Bruce

76y · Male·hospital-acquired pneumonia, age-related frailty, consequences of left neck of f…

…nes recommending six-monthly assessments. Critically, no falls risk reassessment was documented after his previous fall on 8 January 2024. While the immediate fall may have been unavoidable, more frequent risk assessment…

geriatric medicineorthopaedic surgerysystemdelay

QLDhospital2015-03-30

Mulhall, Terrance - Non-inquest findings

48y · Male·myocardial infarction due to ischaemic heart disease due to hypertension

A 48-year-old man died from myocardial infarction due to ischaemic heart disease and hypertension shortly after undergoing urology surgery. Critical failures in clinical communica…

anaesthesiaurologycommunicationdiagnostictelmisartan

VICaged care2011-04-14

Finding into death of Anderina Laura Sanderson

89y · Female·Ischaemic heart disease in a woman with a history of recent assault

Mrs Anderina Sanderson, 89, died from ischaemic heart disease four days after being assaulted by a male resident with dementia in an aged care facility. The for…

geriatric medicinepsychiatrysystemcommunicationparacetamol/codeine

WAhospital2022-08-01

Inquest into the Death of Ronald Joseph BUCKLAND

70y · Male·bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidi…

Ronald Joseph Buckland, aged 70, died in custody at Fiona Stanley Hospital from bronchopneumonia with intra-abdominal carcinoma and multiple comorbidities. A life-sentenced prisoner, he had extensive medical conditions i…

cardiologygastroenterologysystemcommunication

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