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ACThospital2019-11-22

Inquest into death of JAMIE LAWRENCE MITCHELL

36y · Male·Septicaemia and cerebral artery air embolism, due to complications related to cl…

Jamie Lawrence Mitchell, 36, died from septicaemia and cerebral artery air embolism complicating radiofrequency ablation for atrial fibrillation. He developed an atrioesophageal fistula after cardiac ablation at Royal Ad…

cardiologycardiothoracic surgerydiagnosticdelay
WAhospital2019-11-21

Inquest into the Death of Child SH

5y · Male·aspiration pneumonia with terminal palliative care, in a male child with complex…

A 5-year-old boy with severe congenital myopathy and arthrogryposis died from aspiration pneumonia following terminal palliative care. He had multiple complex medical needs including unsafe swallowing, recurrent respirat…

paediatricsrespiratory medicinesystemmorphine
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
NSW2019-11-08

Redacted findings in the joint inquest into deaths arising at music festivals including annexures - 8 November 2019

[18, 21, 23, 19, 22, 19]y · ["male", "female", "male", "male", "male", "female"]·MDMA toxicity (one case mixed MDMA and cocaine toxicity)

This inquest examined six deaths from MDMA toxicity after electronic dance music festivals in NSW between December 2017 and January 2019: Hoang Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), …

emergency medicineintensive carecommunicationproceduralMDMA
NSW2019-11-08

Inquest into the death of six patrons of NSW music festivals

Unknown·MDMA toxicity (3,4-methylenedioxymethylamphetamine toxicity) in each case

Six young people died at NSW music festivals between December 2017 and January 2019 after consuming MDMA (ecstasy) at toxic levels. Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), Joshua Tam (…

emergency medicinetoxicologycommunicationsystemMDMA
VIChospital2019-11-07

Finding into death of Robert Szlamowicz

58y · Male·Aspiration pneumonia and end stage down syndrome

Robert Szlamowicz, a 58-year-old man with Down syndrome, died from aspiration pneumonia complicated by end-stage Down syndrome. He had recurrent hospital admissions for functional decline and aspiration risk due to loss …

intensive carerespiratory medicine
ACThospital2019-11-06

Inquest into death of THEADORA ZAAL

75y · Female·cardiac arrest in the context of aortic stenosis (moderate to severe), coronary …

A 75-year-old woman with significant cardiac history (aortic stenosis, coronary artery disease, left ventricular hypertrophy) underwent elective ankle ulcer debridement surgery. She developed refractory hypotension post-…

anaesthesiasurgerydiagnosticsystem
ACThospital2019-11-04

Inquest into death of JEFFREY BROWN

72y · Male·Haemopericardium due to anti-coagulation treatment for pulmonary thromboemboliti…

Jeffrey Brown, a 72-year-old with recent cardiac surgery (CABG), died from haemopericardium due to anticoagulation treatment for pulmonary thromboembolism. Post-mortem examination revealed fibrinous pericarditis (a known…

cardiothoracic surgerycardiologywarfarin
VIChospital2019-10-31

Finding into death of Armani El-Sayegh

0y · Female·Right ventricular failure secondary to pulmonary atresia with ventricular septal…

Armani El-Sayegh was a seven-month-old infant who died from right ventricular failure secondary to complex congenital heart disease (pulmonary atresia with ventricular septal defect and major aortopulmonary collateral ar…

cardiologyneonatologyprostin
TAShospital2019-10-29

Coroner's Finding: Holmes, Julie Anne

71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision

Julie Anne Holmes, aged 71, died of pneumonia following a cervical spine fracture sustained in a motor vehicle accident that was not diagnosed during her hospital admission. Critical clinical lessons include: (1) paramed…

emergency medicinegeneral surgerydiagnosticprocedural
VIChospital2019-10-29

Finding into death of Ms C

49y · Female·hypoxic ischaemic encephalopathy complicating cardiac arrest due to pulmonary th…

A 49-year-old woman with morbid obesity, obstructive sleep apnoea, and psychiatric history was admitted following deliberate medication overdose. She was intubated, managed in ICU, then transferred to the ward where she …

emergency medicineintensive caresystemheparin
NSWmental health2019-10-25

Inquest into the death of T V

23y · Female·Arrhythmia of unknown aetiology

TV died on 1 November 2016 from arrhythmia of unknown aetiology whilst in MHICU at Prince of Wales Hospital. She was a 23-year-old with severe bipolar disorder, mild intellectual disability and borderline personality tra…

psychiatrycardiologyhaloperidol
NSWhospital2019-10-25

Inquest into the death of Peter SMITH

67y · Male·Gas gangrene with antecedent cause of Clostridium septicum septicaemia

Peter Smith, 67, presented to Cooma Hospital with severe leg muscle cramps and pain on 6 February 2018. Despite appropriate pain management and initial investigation suggesting rhabdomyolysis, he rapidly deteriorated and…

emergency medicinegeneral practicesystemmorphine
QLDcommunity2019-10-18

Hunt, Thomas and Kim, Youngeun

Unknown·drowning (Thomas Hunt); drowning/immersion with head injury (Youngeun Kim)

Two young international visitors died by drowning at Josephine Falls in Queensland's wet tropics, separated by two years. Both were swept away by rapidly rising floodwaters in Bottom Pool after heavy rainfall in the Moun…

emergency medicineintensive carecommunicationdelay
TAShospital2019-10-17

Coroner's Finding: Davies, Eva Fay

87y · Female·left frontal temporal subdural haematoma following closed head injury sustained …

An 87-year-old woman on irreversible anticoagulation suffered a subdural haematoma from a fall. She presented to a community hospital lucid with stable vitals. A CT scan confirmed acute subdural haematoma. The neurosurgi…

neurosurgeryemergency medicinecommunicationdiagnostic
NSWhospital2019-10-08

Inquest into the death of George Kimpton

80y · Male·Vasodilatory shock and multi-organ failure secondary to aspiration and cardiores…

George Kimpton, aged 80, died from vasodilatory shock and multi-organ failure secondary to aspiration pneumonia five hours after cardiopulmonary arrest in hospital following colorectal cancer surgery. He had developed a …

colorectal surgerygeriatric medicinecommunicationsystemmorphine
QLDhome2019-10-02

Banjo, Neil Richard

53y · Male·Traumatic brain injury sustained from police use of force on 25 February 2016, t…

Neil Banjo, a 53-year-old Aboriginal man, died from traumatic brain injury sustained during a police confrontation on 25 February 2016 in Normanton, Queensland. Officers attended a family birthday party to arrest his int…

trauma surgeryemergency medicinesystemdelay
VIChospital2019-10-02

Finding into death of David Sheppard

76y · Male·Intracranial Haemorrhage Secondary to Blunt Head Trauma (Fall) in the Setting of…

A 76-year-old man with newly diagnosed chronic myeloid leukaemia in blast crisis was admitted to hospital with sepsis and pancytopenia from chemotherapy. He suffered multiple falls while confused from sepsis, sustaining …

haematologyinfectious diseasessystemdocumentationhydroxyurea
TAShospital2019-09-30

Coroner's Finding: Frith, Aaron Douglas

36y · Male·pulmonary embolism due to right deep vein thrombosis following repair of rupture…

Aaron Frith, a 36-year-old man with obesity and hypertension, sustained a ruptured right Achilles tendon on 28 August 2018. He underwent surgical repair on 15 September 2018 and was discharged on aspirin prophylaxis. He …

orthopaedic surgeryemergency medicinediagnosticsystemaspirin
VIChospital2019-09-26

Finding into death of Tangimama Tavai

35y · Female·Unascertained

A 35-year-old grand multipara with multiple risk factors (BMI >35, smoking, grand multiparity, pregnancy-induced hypertension) presented at 40+4 weeks with absent foetal movements and was induced on Sunday evening. She e…

obstetricsanaesthesiacommunicationsystemoxytocin
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