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NSWmental health2020-02-07

Inquest into the death of Chella Leijten

57y · Female·metastatic lung carcinoma

Chella Leijten, aged 57, died from metastatic lung carcinoma on 21 March 2018 while an involuntary patient in a palliative care unit. She had longstanding schizoaffective disorder requiring repeated psychiatric admission…

psychiatrypalliative care
NSWhospital2020-02-04

Into the death of Neville Raymond Towner

52y · Male·Acute Respiratory Distress Syndrome

Neville Towner, a 52-year-old man serving a life sentence, died from acute respiratory distress syndrome (ARDS) secondary to severe community-acquired pneumonia. He presented to hospital on 15 June 2018 with respiratory …

respiratory medicineintensive caremethylprednisolone
NSWhospital2019-12-13

Inquest into the death of Lorraine BARNES

85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…

Lorraine Barnes, an 85-year-old woman admitted to Wollongong Private Hospital for convalescence, died from sepsis with aspiration pneumonitis following iatrogenic lung injury. She developed severe malnutrition and electr…

general medicinerespiratory medicinediagnosticsystemciprofloxacin
NSWhospital2019-11-21

Inquest into the death of Ross MARTIN

56y · Male·acute pentobarbitone toxicity

Ross Martin, a 56-year-old man with a long history of depression, died from acute pentobarbitone (Nembutal) toxicity obtained online, combined with toxic levels of zopiclone, less than two weeks after premature discharge…

psychiatrygeneral practicediagnosticcommunicationpentobarbitone
NSWhospital2019-09-04

Inquest into the death of Ivan METCALFE

82y · Male·Complications associated with advanced chronic lung disease

Ivan Metcalfe, aged 82, died of complications from advanced chronic lung disease while in prison custody. He had multiple comorbidities including diabetes, ischaemic cardiovascular disease, and atrial fibrillation. He wa…

respiratory medicinecardiologycommunicationsystemantibiotics
NSW2019-05-27

Inquest into the death of Anthony WRAY

Male·metastatic lung cancer

Anthony Wray died from metastatic lung cancer while in custody at Long Bay Gaol in February 2018. He had been serving a 12-year sentence. Lung cancer with metastases to liver, spleen and brain was diagnosed in October 20…

oncologypalliative care
NSWhospital2018-11-23

BURTON-HO Anqelique File 2015-235464 Findings given by Mag Grahame DSC on 23-11-2018

12y · Female·Cardio-respiratory failure due to aspiration pneumonia

Angelique Burton-Ho, age 12, with VACTERL syndrome and difficult airway, presented to Bowral Hospital ED on 9 August 2015 with respiratory symptoms. She was inadequately triaged initially, then readmitted that evening wi…

anaesthesiaemergency medicinediagnosticdelay
NSWhome2018-08-06

Inquest into the deaths of Diane Michel and John McCain

Unknown·Diane Michel: sharp force injuries to neck and wrists. John McCain: projectile i…

A married couple, both terminally ill with COPD and other serious conditions, died together at home in December 2016. Diane Michel (74) died from sharp force injuries to her neck and wrists; John McCain (76) died from se…

general practicepalliative care
NSWhospital2018-07-18

Inquest into the death of Neville Betteridge

72y · Male·Ruptured abdominal aortic aneurysm

A 72-year-old man died from a ruptured abdominal aortic aneurysm while in custodial care. He was admitted to Prince of Wales Hospital following a fall in prison with symptoms of light-headedness and tunnel vision. Clinic…

emergency medicinegeriatric medicine
NSWhospital2018-07-11

Inquest into the death of Richard Lewis

91y · Male·complications of pneumonia

Richard Lewis, a 91-year-old man in custody, died of pneumonia complicated by underlying ischaemic heart disease and chronic lung disease. He was transferred from the Aged Care and Rehabilitation Unit at Long Bay Hospita…

cardiologyrespiratory medicine
NSWaged care2018-07-10

Inquest into the death of Mr Stephen John

68y · Male·Chronic lung disease

Stephen John, a 68-year-old man in immigration detention, died of chronic lung disease while in lawful custody at Fairfield Nursing Home. He had end-stage COPD and emphysema requiring long-term oxygen therapy and palliat…

respiratory medicinepalliative care
NSWhospital2018-06-06

Inquest into the death of Dr Malay Rana

27y · Male·Loss of airway control and blockage due to aspiration from complications of a sm…

Dr R., a 27-year-old physician with cystic fibrosis, died from aspiration and airway blockage secondary to a small bowel obstruction whilst under dual respiratory-surgical care at Westmead Hospital. Critical clinical les…

respiratory medicinegeneral surgerycommunicationdiagnosticfentanyl
NSWhospital2018-04-27

Inquest into the death of Richard John O'Connor

76y · Male·congestive cardiac failure

Richard John O'Connor, a 76-year-old prisoner, died of congestive cardiac failure at Prince of Wales Hospital after a two-week admission. He had a long history of cardiac disease including previous valve replacement and …

cardiologyrespiratory medicine
NSW2017-11-16

Inquest into the death of Garry Weigand

56y · Male·fatal cardiac arrhythmia due to complications from acute bronchopneumonia and ar…

Garry Weigand, a 56-year-old man with a history of brain injury and intellectual impairment, died in custody 17 days after arrest. He died from a fatal cardiac arrhythmia resulting from acute bronchopneumonia combined wi…

respiratory medicinepsychiatrymetoclopramide
NSWhospital2017-09-07

Inquest into the death of Bruce Thomas

69y · Male·Metastatic non-small cell lung cancer on a background of dilated cardiomyopathy,…

Bruce Thomas, a 69-year-old man serving a custodial sentence, died of metastatic non-small cell lung cancer with concurrent dilated cardiomyopathy, COPD, and hypertension. Lung masses were discovered in May 2015 during a…

oncologycardiology
NSW2017-03-17

Inquest into the death of Ronald BRIZZOLARA

60y · Male·Congestive Cardiac Failure

A 60-year-old Aboriginal man with end-stage COPD, congestive cardiac failure, and ischaemic heart disease died in prison custody. He likely suffered cardiac collapse around 8:30-9:00pm on 25 October 2014, pressed his cel…

cardiologyrespiratory medicinesystemdelay
NSWhome2017-03-15

Inquest into the death of Meaghan Gardner

44y · Female·Acute bronchopneumonia complicating multi-drug toxicity (alprazolam, opiates, be…

Meaghan Gardner, a 44-year-old woman with a history of respiratory problems, pneumonia, schizophrenia, and substance abuse, died from acute bronchopneumonia complicated by multi-drug toxicity (alprazolam, opiates, benzod…

respiratory medicinepsychiatrydelaycommunicationalprazolam
NSWhospital2016-10-26

Inquest into the death of Audrey MacGREGOR

88y · Female·combined effects of an overdose of hydromorphone and complications of pneumonia …

An 88-year-old woman with chronic lung disease, heart disease, and recent pneumonia following faecal transplant for clostridium difficile colitis was prescribed 0.5 mg hydromorphone subcutaneously for respiratory distres…

cardiologyrespiratory medicinemedicationcommunicationhydromorphone
NSW2016-03-06

Inquest into the death of Laurence Bede O Connor

73y · Male·Combined effects of ischaemic heart disease and chronic obstructive pulmonary di…

A 73-year-old man in prison custody died from combined ischaemic heart disease and chronic obstructive pulmonary disease. He had a significant cardiac history including aortic repair and endocarditis, plus severe COPD wi…

cardiothoracic surgeryrespiratory medicinewarfarin
NSWhospital2015-08-17

Inquest into the death of Manjit SINGH

33y · Male·hypoxic respiratory failure following right pneumonectomy for treatment of sever…

Manjit Singh, a 33-year-old Indian 457 visa worker, died from hypoxic respiratory failure following a pneumonectomy for treatment of severe pulmonary tuberculosis. He had latent TB identified pre-arrival in India. Critic…

respiratory medicinecardiothoracic surgerydiagnosticcommunicationtuberculosis medications

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