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VIChospital2019-07-16

Finding into death of Baby J

1y · Unknown·Hypoxic ischaemic encephalopathy post cardiac arrest due to nicotine toxicity

Baby J, an 18-month-old child, ingested liquid nicotine that had been left unattended on a dining table. The concentrated nicotine product was illegal in Australia, imported from the USA for use in e-cigarettes. Within m…

intensive careemergency medicineliquid nicotine
TAShome2019-06-26

Coroner's Finding: Lukendlay, Charlotte (OM) Findings

0y · Female·global hypoxic brain injury caused by prolonged cessation of breathing arising f…

An 11-week-old healthy infant died from global hypoxic brain injury following cardiac arrest at home. Multiple rib fractures and a clavicle fracture in various stages of healing indicated repeated non-accidental trauma i…

paediatricsintensive caresystem
ACThospital2019-06-25

Inquest into the death of Jay Alan Paterson

43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …

Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone table…

general practicepain medicinesystemproceduraloxycodone
WAhospital2019-06-21

Inquest into the Death of Gerda Theresia DUNKEL

44y · Female·pulmonary thromboembolism in a woman with likely myeloproliferative neoplasm

A 44-year-old previously healthy woman with BMI 30.5 and minimal comorbidities (snoring, back pain, knee pain) underwent elective sleeve gastrectomy for weight loss. Nine days post-op she presented with splenic rupture r…

general surgerybariatric surgerydiagnosticcommunicationheparin
VICcommunity2019-06-18

Finding into death of Yara Sturak Mignon

35y · Male·Hypoxic brain injury complicating cardiac arrest in the setting of combined hero…

Yara Sturak Mignon, a 35-year-old with a 10-year heroin addiction, was found unconscious in a restaurant bathroom on Victoria Street Richmond in November 2018. He had combined heroin, alcohol, and doxylamine (antihistami…

emergency medicineintensive caresystemheroin
VIChospital2019-06-17

Finding into death of Baby L

0y · Female·OEIS Complex (Omphalocoele, Exstrophy of Cloaca, Imperforate Anus, Spinal Defect…

Baby L died aged 7 days from OEIS Complex (a severe congenital condition involving omphalocoele, exstrophy of cloaca, imperforate anus, and spinal defects) combined with prematurity at 32 weeks gestation. The defect was …

neonatologypaediatric surgery
NSWhospital2019-06-14

Inquest into the death of Melissa King

33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…

Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraem…

intensive careendocrinologydiagnosticcommunicationglycoprep
SAhospital2019-06-12

Coroner's Finding: NGUYEN An Hoang Le

4y · Male·acute lymphoblastic leukaemia

An Hoang Le Nguyen, a 4-year-old boy, died from acute lymphoblastic leukaemia with CNS involvement. He presented with a 4-day history of abdominal pain, lethargy, fever, and respiratory symptoms at Royal Darwin Hospital …

haematologyintensive carechemotherapy
SAhospital2019-06-12

Coroner's Finding: CHEETHAM Robert Boyd

84y · Male·dilated cardiomyopathy with cardiomegaly due to pulmonary hypertension and valvu…

An 84-year-old man with advanced cardiac disease (dilated cardiomyopathy, pulmonary hypertension, atrial septal defect) and chronic schizophrenia died of natural causes while subject to a Mental Health Act detention orde…

cardiologypsychiatry
NSWmental health2019-06-04

Inquest into the death of Andrea Sewell

46y · Female·hypoxic ischaemic brain injury as a result of cardiac arrest following a choking…

Andrea Sewell, a 46-year-old woman with Osmotic Demyelination Syndrome (ODS) and acute psychiatric illness, died from hypoxic brain injury following a choking episode during a meal in a psychiatric intensive care unit (P…

psychiatryneurologyantipsychotic medications
SAhospital2019-05-31

Coroner's Finding: CHAPLIN Gray Clyde

81y · Male·multi-organ failure complicating multiple right-sided rib fractures due to a fal…

An 81-year-old man sustained multiple rib fractures from a 1.5m ladder fall. Initial assessment at a rural hospital on day one was appropriate. However, when chest X-rays on day two revealed 9 rib fractures, the treating…

general practiceemergency medicinediagnosticdelaymorphine sulphate
SAaged care2019-05-29

Coroner's Finding: FIELD Glenda Rae

59y · Female·Hypoxic-ischaemic encephalopathy due to acute upper airway obstruction

Glenda Rae Field, aged 59, died from hypoxic-ischaemic encephalopathy due to acute upper airway obstruction by food bolus while eating dinner at her aged care facility. She was a resident at Clearview Manor, a locked car…

emergency medicineintensive carefluoxenol
WAmental health2019-05-22

Inquest into the Death of Pamela Edith ASHLEY

64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…

A 64-year-old woman with bipolar disorder, severe obstructive sleep apnoea, obesity and diabetes presented with acute psychotic relapse following stress and sleep deprivation. Initially admitted to ED where she was sedat…

psychiatryemergency medicinecommunicationsystemchlorpromazine
TAShospital2019-05-17

Coroner's Finding: Nichols, James Raymond

23y · Male·traumatic closed head injury (diffuse axonal injury)

A 23-year-old male died from traumatic closed head injury (diffuse axonal injury) following a single-vehicle motor crash. He was speeding (142 km/h in a 110 km/h zone), not wearing a seatbelt, and had a blood alcohol lev…

intensive careneurologyalcohol
WAhospital2019-05-13

Inquest into the Death of Daniel Josef ADWENT

44y · Male·gunshot wound to abdomen

A 44-year-old male died from a gunshot wound to the abdomen sustained during a police response to a domestic violence incident. He became aggressive, wielded a knife, and lunged at police after Taser and pepper spray fai…

emergency medicinegeneral surgerycommunicationdelay
VIChospital2019-05-10

Finding into death of Simon Smith

22y · Male·acute blood loss from incised injuries to left forearm

Simon Smith, a 22-year-old with end-stage renal failure requiring dialysis and complex comorbidities, died by suicide during hospitalization. Despite multiple psychiatric assessments finding he had capacity to make treat…

psychiatrynephrologycommunicationsystemtemazepam
SAhospital2019-05-08

Coroner's Finding: JONES Melissa Irene

45y · Female·methicillin resistant staphylococcus aureus (MRSA) endocarditis of the mitral va…

A 45-year-old woman with chronic renal failure requiring dialysis and bipolar disorder died of MRSA endocarditis of the mitral valve. She was detained under a Mental Health Act order due to manic episodes and non-complia…

nephrologypsychiatrylithium
SAhospital2019-05-08

Coroner's Finding: CATINO Giovanni

91y · Male·ischaemic and hypertensive heart disease

Giovanni Catino, aged 91, died of ischaemic and hypertensive heart disease while detained under a Mental Health Act inpatient treatment order at Repatriation General Hospital. He had advanced Alzheimer's dementia with be…

psychiatrygeriatric medicineclonazepam
VIChospital2019-04-24

Finding into death of Dennis John Wright

72y · Male·head injuries sustained in a fall from a ladder

A 72-year-old man died from unsurvivable head injuries sustained in a fall from a domestic ladder. He was climbing down from his roof when he slipped and fell backwards onto concrete. Despite rapid helicopter transport t…

trauma surgeryneurosurgerymorphine
QLDhome2019-04-17

Davis, John

50y · Male·Hypoxic-ischaemic encephalopathy secondary to choking on food bolus

A 50-year-old man with acquired brain injury and intellectual disability died from hypoxic-ischaemic encephalopathy following aspiration of a food bolus during lunch at his disability care residence. The carer appropriat…

emergency medicineparamedicinediagnosticcommunicationmidazolam
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