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WAhospital2019-09-23

Inquest into the Death of Dylan James RILEY

16y · Male·pulmonary embolism secondary to nephrotic syndrome

Dylan Riley, a 16-year-old with steroid-responsive minimal change nephrotic syndrome, died from a massive pulmonary embolism (PE) on 1 August 2015. He presented to Rockingham Hospital with dyspnoea, hypoxia, tachycardia …

nephrologyintensive caredelayenoxaparin
NThospital2019-09-20

Inquest into the death of Joanne Craig

57y · Female·multi-organ failure due to sepsis caused by streptococcus pneumoniae infection

Joanne Craig, a 57-year-old Aboriginal woman, presented to Katherine District Hospital on 24 January 2018 with fever, vomiting, and cough. She had streptococcus pneumoniae sepsis with elevated inflammatory markers from 1…

emergency medicinegeneral practicediagnosticcommunicationondansetron
TAShospital2019-09-17

Coroner's Finding: O'Brien, Mark Andrew

42y · Male·Multiple traumatic injuries of head and chest sustained in a motorcycle crash

Mark Andrew O'Brien, 42, died from multiple traumatic injuries sustained in a motorcycle crash on 13 January 2017 and died 18 January 2017 at Royal Hobart Hospital. He was riding a Honda 125cc motorcycle on a P1 novice l…

trauma surgeryneurosurgery
VIChospital2019-09-17

Finding into death of Elizabeth Geiger

69y · Female·Aspiration pneumonia in a woman with intellectual disability

Elizabeth Geiger, a 69-year-old woman with intellectual disability living in a disability group home, died from aspiration pneumonia after presenting with constipation. She was seen by her GP on 24 July 2017 who examined…

general practiceintensive carecoloxyl
VIChospital2019-09-16

Finding into death of Marco Angelo Virgona

45y · Male·Aspiration pneumonia with acquired brain injury as a contributing factor

Marco Virgona, a 45-year-old man with acquired brain injury and epilepsy, died from aspiration pneumonia at Frankston Hospital on 23 May 2017. He initially presented to Ambulance Victoria in the morning with vomiting and…

emergency medicineintensive carewarfarin
QLDhospital2019-09-05

Mrs MDF - Non-inquest findings

76y · Female·multisystem organ failure due to or as a consequence of ischaemic small intestin…

A 76-year-old woman presented to hospital with abdominal pain and was found on CT scan to have ischaemic colitis with signs of profound shock. The Consultant Surgeon decided on conservative management with fluid resuscit…

surgeryintensive carediagnosticcommunicationtramadol
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
SAhospital2019-08-30

Coroner's Finding: SCHULZE Brian John

68y · Male·Ischaemic heart disease (operated); severe native coronary artery atheroma with …

Brian John Schulze, aged 68, died of ischaemic heart disease (operated) while subject to a Mental Health Act inpatient treatment order at Flinders Medical Centre. He presented with falls, confusion, and agitation followi…

cardiologypsychiatrymorphine
VIChospital2019-08-30

Finding into death of Agostino Cutugno

57y · Male·Small bowel perforation complicating small bowel obstruction arising from intra-…

Agostino Cutugno, a 57-year-old prisoner with intellectual disability (IQ 55) and history of self-inflicted abdominal stab wounds, died from small bowel perforation complicating obstruction due to intra-abdominal adhesio…

general surgeryintensive carecommunicationsystemproton pump inhibitors
WA2019-08-14

Inquest into the Death of Anita Jade BOARD

8y · Female·complications of multiple injuries sustained in motor vehicle crash

Eight-year-old Anita Board died from catastrophic brain injury sustained in a motor vehicle crash at Perth Motorplex on her first junior drag racing licensing attempt. Her dragster failed to slow adequately after the fin…

emergency medicineintensive caresystemprocedural
VIChospital2019-08-07

Finding into death of Leon Edward Balshaw

55y · Male·Bronchopneumonia in a man with a healing myocardial infarction

Leon Edward Balshaw, aged 55, died from bronchopneumonia complicating a healing myocardial infarction while in police custody. He was arrested on 25 January 2018 following a domestic dispute and taken to Bairnsdale Regio…

emergency medicineintensive care
VIC2019-08-07

Finding into death of Bartosz Zgadzaj

39y · Male·Hypoxic ischaemic encephalopathy complicating acute upper airway obstruction by …

Bartosz Zgadzaj, a 39-year-old man with cerebral palsy and intellectual disability, died from hypoxic ischaemic encephalopathy secondary to acute airway obstruction from a food bolus. He choked while eating unsupervised …

emergency medicineintensive carediagnosticcommunicationmidazolam
NSWhospital2019-08-07

Inquest into the death of Pauline KESSELL

53y · Female·multiple organ failure as a result of septic shock

Pauline Kessell, aged 53, died from septic shock caused by overwhelming sepsis following endoscopic pyeloscopy with laser lithotripsy for a 5cm infected staghorn calculus on 12 August 2015. Critical clinical lessons: (1)…

urologyanaesthesiadiagnosticproceduralgentamicin
WAhospital2019-08-02

Inquest into the Death of Timothy James CHANDLER

52y · Male·multiple organ failure and pulmonary thromboemboli complicating generalised seps…

A 52-year-old man with longstanding refusal of medical care presented with severe cellulitis, sepsis, and previously undiagnosed heart failure secondary to sleep apnoea. He lacked capacity to consent to treatment due to …

emergency medicinegeneral medicine
VIChospital2019-08-01

Finding into death of Tyla Jade Hovenbitzer

18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…

An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…

paediatricsgeneral practicesystemdelaytemazepam
WAhospital2019-07-30

Inquest into the Death of Child KT (Name Subject to Suppression Order)

7y · Male·cardiorespiratory failure in a child with cerebral palsy and epilepsy, with acut…

Child KT (Vinnie), age 7, died of cardiorespiratory failure from cerebral palsy and epilepsy after a prolonged hospital admission. He had complex medical needs including chronic respiratory disease, requiring PEG feeding…

paediatricsintensive caresystemmorphine
VIChospital2019-07-30

Finding into death of Allison Judith Allan

43y · Female·Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxic…

43-year-old woman with epilepsy and depression died from hypoxic ischaemic brain injury after ingesting 15g sodium valproate and 750ml vodka. Critical failures occurred across multiple settings: VPIC provided incomplete …

emergency medicineintensive carediagnosticcommunicationsodium valproate
QLDhospital2019-07-24

Mr P - Non-inquest findings

47y · Male·Pulmonary thrombo-embolism secondary to deep vein thrombosis in setting of morbi…

A 47-year-old man with morbid obesity presented with respiratory failure, productive cough, and calf swelling. His GP appropriately suspected both pneumonia and pulmonary embolism (PE), requesting urgent CTPA. At Townsvi…

intensive careemergency medicinediagnosticcommunicationheparin
WAhospital2019-07-22

Inquest into the Death of Arthur James BONNEY

59y · Male·ischaemic heart disease in the context of acute-on-chronic kidney failure associ…

Arthur James Bonney, a 59-year-old prisoner with advanced cardiac disease, chronic kidney disease, and diabetes, underwent a CT scan with iodinated contrast on 30 July 2015 at Fiona Stanley Hospital. Critical failures oc…

radiologycardiologydiagnosticproceduraliodinated contrast medium
NSWhospital2019-07-22

Inquest into the death of Nicholas Wells

24y · Male·Peritonitis secondary to a perforation of the small bowel

Nicholas Wells, a 24-year-old man, died from peritonitis secondary to small bowel perforation sustained in a motor vehicle accident. Although he was suspected of having a bowel injury at 11am on admission, he was placed …

emergency medicinesurgerydiagnosticcommunicationmethamphetamine
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