918 results
77y · Female·haemorrhagic diathesis due to warfarin toxicity
Ruby Mabel Edwards, 77, died from haemorrhagic diathesis due to warfarin toxicity after 84 days in a rural hospital. She had a prosthetic aortic valve requiring anticoagulation. INR monitoring was inadequate: no tests fo…
21y · Male·Closed head injury and retroperitoneal and pelvic haematoma due to fractured pel…
A 21-year-old man died from massive internal bleeding into the pelvis and retroperitoneum following a motor vehicle collision with a stobie pole in rural South Australia. He was trapped for over 2 hours before extricatio…
18y · Male·Gunshot wound to the head (self-inflicted)
Daniel Aaron Greenland, 18 years old, died from a self-inflicted gunshot wound to the head on 3 February 2003 after shooting his stepmother. Evidence shows he attended the shed with pre-formed suicidal intent, writing fa…
74y · Male·cardiac and renal failure complicating treatment of infected ischaemic toes resu…
Glenn Howard Raphael, 74-year-old admitted for infected ischaemic toe secondary to diabetes mellitus. During his 17-day hospital stay, he developed acute renal failure leading to cardiac arrest and death. Critical failur…
63y · Male·pancreatic carcinoma
Gary Michael McMahon, aged 63, died of pancreatic carcinoma at Royal Adelaide Hospital on 5 January 2005 while detained under the Mental Health Act. He was admitted following collapse at home with a history of diabetes, …
22y · Male·Mixed Diflunisal and Buproprion (Zyban) toxicity
A 22-year-old man presented to Royal Adelaide Hospital's Emergency Department after taking approximately 110 Zyban (bupropion) tablets as a suicide attempt. Unknown to treating staff, he had also ingested a potentially l…
79y · Female·cardio-respiratory arrest consequent upon the aspiration of food
A 79-year-old woman with post-stroke dysphagia died from aspiration of food while hospitalised. A speech pathologist prescribed a minced diet after an unsuccessful soft diet trial, but the patient received a soft diet me…
34y · Male·multi-organ failure with right-sided tension pneumothorax
A 34-year-old man with a ruptured spleen and fractured ribs presented to the Emergency Department on multiple occasions with abdominal and chest pain. He was discharged on 28 February, 5 March and 6 March without admissi…
19y · Male·Unknown - presumed dead following disappearance
This coronial finding concerns the disappearance of Daniel Nicholas Sheppard, a 19-year-old who vanished from Port Adelaide Railway Station on New Year's Day 1995 after a night of socialising in Adelaide. The coroner fou…
35y · Male·pulmonary thromboembolism due to left deep calf vein thrombosis complicating lef…
John Matthew Murray, aged 35, died of pulmonary thromboembolism complicating pelvic and leg fractures sustained in a motorcycle accident. He was admitted to Royal Adelaide Hospital and underwent extensive orthopaedic sur…
35y · Male·pulmonary thromboembolism due to left deep calf vein thrombosis complicating lef…
John Matthew Murray, aged 35, died from pulmonary thromboembolism caused by deep vein thrombosis following a severe motorcycle accident that resulted in pelvic and leg fractures. He was treated surgically at Royal Adelai…
24y · Male·consequences of hanging
Damian John Cook, aged 24, died by hanging in his cell at Adelaide Remand Centre after 5 months in custody. His suicidal ideation on the day of death (following difficult phone calls with his ex-partner regarding access …
57y · Female·right bronchopneumonia following hypoxic brain damage secondary to cardiac arres…
A 57-year-old woman with chronic schizophrenia and non-insulin dependent diabetes was admitted to a psychiatric ward after detention under the Mental Health Act. She was found in cardiac arrest on 8 December 2001 and suf…
41y · Male·multi-organ failure and staphylococcal septicaemia following pulmonary and aorti…
A 41-year-old man with a pre-existing aortic valve abnormality developed staphylococcal septicaemia, likely initiated by Q fever exposure at his abattoir workplace or a finger laceration. He presented with fever and ches…
71y · Male·Combined effects of ischaemic and valvular heart disease
A 71-year-old man with chronic paranoid schizophrenia was detained under the Mental Health Act after community mental health workers observed physical signs of heart failure (dyspnea, bilateral pitting edema) during home…
69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…
A 69-year-old woman presented to the Emergency Department with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood t…
64y · Female·Respiratory arrest secondary to morphine overdosage on a background of mild to m…
A 64-year-old woman died from respiratory arrest secondary to morphine overdose after ingesting 17 tablets of slow-release morphine (Kapanol) and diazepam. Initial emergency assessment by an intern was appropriate, but c…
0y · Male·cardiogenic shock and neonatal encephalopathy
Matthew Hutchinson, born at 1 day of age at Flinders Medical Centre, died from cardiogenic shock and neonatal encephalopathy. While obstetric care was appropriate, neonatal care was significantly deficient. Critical fail…
45y · Male·bronchopneumonia and suppurative bronchitis complicating hypoxic brain damage
Ian McLeod, a 45-year-old lawyer with alcohol dependence and depression, died from hypoxic brain damage and bronchopneumonia following a hanging while in custody at Yatala Labour Prison. Multiple system failures contribu…
30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…
Candice Mackenzie Wallace-Mohlmann, a 30-year-old woman with chronic schizophrenia and substance abuse history, died from hypoxic brain injury caused by self-injection of vecuronium and atropine obtained from a hospital …
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