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SAhospital2019-10-29

Coroner's Finding: PEMBERTON Graham Ashton

87y · Male·aspiration pneumonia, urinary tract infection and general inanition complicating…

Graham Pemberton, 87 years old with advanced Alzheimer's dementia, died of aspiration pneumonia, urinary tract infection, and general inanition. He was admitted to hospital multiple times in 2015 with behavioural disturb…

geriatric medicinepsychiatry
SAhospital2019-08-30

Coroner's Finding: SHUEARD Braydon Adrian

60y · Male·Sepsis due to pressure ulcers due to immobility on a background of advancing fro…

A 60-year-old man with frontotemporal dementia, diabetes, and ischaemic heart disease died from sepsis secondary to pressure ulcers while subject to a Mental Health Act inpatient treatment order. He developed sacral and …

psychiatrygeneral medicinehaloperidol
SAhospital2019-06-21

Coroner's Finding: COOK Janet Ann

79y · Female·multi-organ failure as a result of ischaemic and valvular heart disease with uri…

Janet Ann Cook, aged 79, died of multi-organ failure complicated by hydromorphone toxicity on 30 September 2015. She was mistakenly administered 16mg hydromorphone intended for another patient (room 28 vs room 26) on 21 …

cardiologypalliative caremedicationcommunicationhydromorphone
SA2019-06-12

Coroner's Finding: WRIGHT Martin Norman

59y · Male·Chronic liver disease due to alcoholism and chronic hepatitis C infection with c…

Martin Norman Wright, aged 59, died in Yatala Labour Prison on 26 August 2015 from chronic liver disease due to alcoholism and chronic hepatitis C infection, with contributing ischaemic heart disease and chronic obstruct…

emergency medicinegeneral medicinewarfarin
SA2019-04-15

Coroner's Finding: COLLINS Robert Edwin

64y · Male·end-stage interstitial lung disease

Robert Edwin Collins, aged 64, died in Yatala Labour Prison from end-stage interstitial lung disease. He had advanced pulmonary fibrosis, recurrent pneumonia, obesity, and poor mobility. Following hospitalisation at Roya…

respiratory medicinepalliative care
SAhospital2018-11-05

Coroner's Finding: SIZE Mervyn Eric

77y · Male·multi-organ failure due to general inanition on a background of end-stage Alzhei…

Mervyn Eric Size, a 77-year-old man with end-stage Alzheimer's dementia, died from multi-organ failure due to general inanition while subject to a Level 2 Inpatient Treatment Order at Repatriation General Hospital. His c…

geriatric medicinepsychiatryoxazepam
SAhospital2018-07-27

Coroner's Finding: CUTTS Charles Desmond

70y · Male·aspiration pneumonia due to seizures

70-year-old man with insulin-dependent diabetes, cognitive impairment, depression, alcohol abuse history, and seizure disorder died from aspiration pneumonia following seizures while admitted under mental health legislat…

emergency medicinepsychiatryrisperidone
SAhospital2018-05-23

Coroner's Finding: LA BELLA Claudia

28y · Female·aspiration of gastric contents complicating laxative abuse

A 28-year-old woman died from aspiration of gastric contents complicating severe laxative abuse. She fabricated a terminal cancer diagnosis to conceal anorexia nervosa and factitious disorder. During a RAH admission, a C…

general practicegeneral medicinediagnosticcommunicationbisacodyl
SAhospital2018-04-26

Coroner's Finding: JEISMAN Leonie Faye

45y · Female·Type 2 respiratory failure and aspiration pneumonia on a background of end-stage…

Leonie Jeisman, a 45-year-old woman with chronic obstructive pulmonary disease (COPD), schizoaffective disorder, obesity, and obstructive sleep apnoea, died from Type 2 respiratory failure and aspiration pneumonia. She w…

respiratory medicinegeneral medicine
SAhospital2018-03-29

Coroner's Finding: BUTSON Graham Joseph

81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…

Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass w…

orthopaedic surgerygeneral medicinesystemwarfarin
SAhospital2017-12-12

Coroner's Finding: HODGINS William Albert

95y · Male·multi-organ failure due to sepsis and general inanition on a background of advan…

William Albert Hodgins, aged 95, died of multi-organ failure due to sepsis and general inanition on a background of advanced vascular dementia and ischaemic heart disease. He was admitted under a Level 2 Inpatient Treatm…

psychiatrygeneral medicine
SAhospital2017-11-17

Coroner's Finding: CAMERON George William

76y · Male·pneumonia and exacerbation of chronic obstructive airway disease

George William Cameron, aged 76, died from pneumonia and exacerbation of chronic obstructive airway disease at Noarlunga Hospital. He was admitted with acute alcohol withdrawal, confusion, and respiratory symptoms. A Lev…

psychiatrygeneral medicinesalbutamol
SAhospital2017-08-25

Coroner's Finding: KELBIN William Thomas

81y · Male·gastrointestinal haemorrhage and multi-organ failure on a background of severe d…

William Thomas Kelbin, aged 81, died from gastrointestinal haemorrhage and multi-organ failure on a background of severe dementia. He had been placed under guardianship with detention powers after becoming unable to self…

geriatric medicinegeneral medicine
SAhospital2017-08-25

Coroner's Finding: WARNE Garry Robert

58y · Male·pneumonia on a background of adenocarcinoma of the lung stage 4, ischaemic heart…

58-year-old male prisoner died from pneumonia complicated by stage 4 lung adenocarcinoma, ischaemic heart disease, and chronic emphysema. He presented with critical leg ischaemia requiring femoral endarterectomy, develop…

vascular surgerycardiology
SAaged care2017-05-30

Coroner's Finding: ABBOTT Raymond

70y · Male·chronic obstructive lung disease with emphysema on a background of advanced vasc…

Raymond Abbott, a 70-year-old man with chronic obstructive pulmonary disease, emphysema, vascular dementia, opioid addiction and alcohol abuse, died of COPD with emphysema at a residential care facility. He was admitted …

respiratory medicinegeneral medicinemidazolam
SAaged care2017-05-30

Coroner's Finding: McKEEVER David Michael

69y · Male·aspiration pneumonia on a background of ischaemic heart disease and diabetes

A 69-year-old man with dementia, ischaemic heart disease, and poorly controlled diabetes died of aspiration pneumonia in aged care. He had been subject to guardianship orders after assessment showed he lacked capacity to…

geriatric medicinepsychiatry
SAhospital2017-04-19

Coroner's Finding: ADAMSON Jean Anne

78y · Female·aspiration on a background of psychogenic dysphagia, intellectual impairment and…

Jean Anne Adamson, aged 78, died from aspiration on a background of psychogenic dysphagia, intellectual impairment, and chronic schizophrenia. She had experienced a swallowing phobia that recurred in September 2014, lead…

general medicinepsychiatrymorphine
SAhospital2017-04-19

Coroner's Finding: RAYNER Augustine Durham

88y · Male·bilateral acute bronchopneumonia on a background of chronic obstructive airways …

An 88-year-old man with chronic obstructive pulmonary disease and chronic schizophrenia died of bilateral acute bronchopneumonia while subject to a Mental Health Act detention order at a teaching hospital. He was admitte…

psychiatrygeneral medicine
SAhospital2017-04-07

Coroner's Finding: MAYELL Edward John

83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…

An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…

emergency medicinegeneral practicediagnosticmedicationceftriaxone
SAhospital2016-09-05

Coroner's Finding: D'ARCY-EVANS Andrew Eyre

30y · Male·Disseminated mycobacterium avium complex infection complicating HIV infection

A 30-year-old man with HIV infection died from disseminated mycobacterium avium complex (MAC) infection. He had been subject to a guardianship order since July 2013 due to repeated refusal of antiretroviral therapy and o…

infectious diseasesgeneral medicine

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