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NSW2020-03-25

Inquest into the death of Mahmoud ALLAM

28y · Male·MRSA sepsis

Mahmoud Allam, a 28-year-old man, died from MRSA sepsis whilst in custody at Parklea Correctional Centre. He initially presented with upper respiratory symptoms on 11 June 2016, followed by increasing symptoms including …

infectious diseasesemergency medicinecommunicationsystemflucloxacillin
NSWhospital2020-03-17

Inquest into the death of Esteban FRANCO-GARCES

11y · Male·Sepsis

An 11-week-old premature infant presented to the ED with fever, lethargy and poor feeding. Despite initial suspicion of sepsis at 1:15pm, antibiotics were not administered until 4pm—a three-hour delay. Key failures inclu…

emergency medicinepaediatricsdiagnosticdelayantibiotics
NSWhospital2020-03-04

Inquest into the death of Paul MORTIMER

65y · Male·ischaemic heart disease following complications of colorectal surgery

A 65-year-old man with significant comorbidities (cardiomyopathy, diabetes, obesity) underwent colorectal surgery for adenocarcinoma. Post-operative course was complicated by anastomotic breakdown causing sepsis on day 1…

colorectal surgeryintensive careproceduralsystemenoxaparin
VIChospital2020-02-28

Finding into death of Keith Walter Sharp

63y · Male·Cerebral infarction complicating vertebral artery dissection following motor veh…

Keith Walter Sharp, 63, sustained a motor vehicle collision causing vertebral artery dissection and subsequent cerebral infarction. At Albury Base Hospital, initial CT imaging at 10:44am identified significant cervical s…

emergency medicineradiologydelaydiagnosticaspirin
NSW2020-02-28

Inquest into the death of Eric WHITTAKER

35y · Male·subarachnoid haemorrhage with antecedent ruptured cerebral artery aneurysm

Eric Whittaker, a 35-year-old Aboriginal man, died from a subarachnoid haemorrhage caused by a ruptured cerebral artery aneurysm while in remand custody at Parklea Correctional Centre. On 2 July 2017, he made 20 emergenc…

correctional healthneurologydiagnosticcommunicationamphetamine
ACThospital2020-02-20

Inquest into death of JULIE ANN HERMANS

54y · Female·Multiple organ failure, due to pneumonia in a patient with Guillain-Barré syndro…

Julie Ann Hermans, a 54-year-old Aboriginal woman with Guillain-Barré syndrome, quadriplegia, diabetes, and recurrent infections, died from multiple organ failure due to hospital-acquired pneumonia during an ICU admissio…

intensive caregeneral medicine
VICcommunity2020-02-12

Finding into death of Stephen James Johnston

57y · Male·Complications of multiple blunt force injuries in a man with ischaemic heart dis…

Stephen Johnston, a 57-year-old man with ischaemic heart disease, obesity, depression and alcohol dependence, was assaulted on 7 December 2016 by Kevin Knowles and Amanda Bourke after an evening of drinking. Johnston suf…

emergency medicineintensive caredelayoxycodone
NSW2020-02-05

Inquest into the death of Francis McCann

49y · Male·complications of a cervical spine injury

Francis McCann, a 49-year-old man in custody with a history of schizophrenia, anxiety, and self-harm, fell from his bed during sleep on 24 September 2017, sustaining a serious cervical spine injury (C4-C5 with canal sten…

orthopaedic surgeryneurosurgery
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
NSWcommunity2020-01-24

Into the death of Thomas Redman

18y · Male·Incised wound to right axilla with complete transection of basilic vein, brachia…

Thomas Redman, aged 18, sustained a catastrophic laceration to his right axilla involving complete transection of major arteries and veins after putting his arm through a glass window at a rural property near Gloucester,…

emergency medicinetrauma surgerycommunicationsystemoxygen
VIChome2020-01-14

Finding into death of A S

46y · Female·Combined drug toxicity in a woman found in a bath

A 46-year-old woman with borderline personality disorder and bipolar affective disorder type 2 died from combined drug toxicity. She had a long history of overdose attempts, often without clear suicidal intent, and was u…

psychiatrygeneral practicecommunicationsystemphentermine
SAhospital2020-01-10

Coroner's Finding: PLAYFORD Aldona Mariana

84y · Female·sepsis and cardiac failure in a woman with hypertensive ischaemic and valvular h…

Aldona Mariana Playford, an 84-year-old woman with extensive medical comorbidities including ischaemic heart disease, chronic renal failure, and severe biventricular dysfunction, died of sepsis and cardiac failure. She w…

cardiologypsychiatryfurosemide
SAhospital2020-01-10

Coroner's Finding: FIORETTI Louisa Jill Josephine

19y · Female·2,4-dinitrophenol toxicity

A 19-year-old woman died from 2,4-dinitrophenol (DNP) toxicity after intentionally ingesting approximately 50 x 250mg capsules purchased online. She presented to Flinders Medical Centre with an Inpatient Treatment Order …

toxicologyemergency medicine2,4-dinitrophenol
TAShospital2020

Coroner's Finding: Bond, Johnathon Lee

51y · Male·mixed prescription drug toxicity (amisulpride, diazepam and mirtazapine)

A 51-year-old man with schizophrenia, depression and early dementia died from mixed prescription drug toxicity (amisulpride, diazepam, mirtazapine) after a deliberate overdose. He had recently presented to hospital with …

psychiatryemergency medicinesystemdelayamisulpride
WAhospital2019-12-20

Inquest into the Death of Child TJW

7y · Female·aspiration pneumonia leading to multi-organ failure in a female child with compl…

A child with severe cerebral palsy, hypoxic ischaemic encephalopathy, microcephaly and seizure disorder died of aspiration pneumonia leading to multi-organ failure. Born with severe perinatal brain injury, she had comple…

paediatricsneurologymorphine
NSWhospital2019-12-20

Inquest into the death of Blair DALTON

35y · Female·hypoxic brain injury, with strangulation being an antecedent cause

Blair Dalton died from hypoxic brain injury following strangulation by her partner LP on 26 September 2017. She was resuscitated at the scene and admitted to Gosford Hospital ICU but suffered irreversible brain injury. L…

emergency medicineintensive care
NSWhospital2019-12-19

Inquest into the death of Lesley ARNDELL

61y · Female·multi organ failure due to abdominal sepsis

Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery requ…

general surgeryintensive caremedicationcommunicationpiperacillin/tazobactam
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
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
SAhospital2019-12-03

Coroner's Finding: TAEGER Luke Victor

89y · Male·pneumonia on a background of advanced Parkinson's disease and dementia

An 89-year-old man with advanced Parkinson's disease and dementia died of aspiration pneumonia following hospital admission for behavioural management. He was subject to an Inpatient Treatment Order and required chemical…

geriatric medicinepsychiatrythyroxine
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