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TAShome2018-05-31

Coroner's Finding: Hayes, Teegan Rose Dana

0y · Female·hypoxic brain injury following respiratory arrest due to accidental suffocation …

A 24-day-old infant died from hypoxic brain injury following accidental suffocation whilst co-sleeping with her intoxicated mother. The parents were known to child protection services (CPS) due to intellectual disabiliti…

paediatricsintensive caresystemcommunicationalcohol
WAcommunity2018-05-30

Inquest into the Death of Lachlan James MITCHELL

2y · Male·Hypoxic brain injury following immersion (drowning)

Lachlan Mitchell, a 2-year-old with global developmental delay and hypermobility, drowned in a swimming pool at a family day care home on 9 November 2015, suffering fatal hypoxic brain injury. While swimming pools were n…

emergency medicineintensive caresupervisionsystem
TAShospital2018-05-30

Coroner's Finding: Forward, Trudi Maree

53y · Female·sepsis and multiple organ failure attributable to infarction/necrosis of small b…

A 53-year-old woman with Type II diabetes, obesity, and Korsakoff dementia presented with acute severe abdominal pain from superior mesenteric artery (SMA) thrombosis at 3:00 AM on 19 August. Despite elevated lactate, me…

emergency medicinegeneral surgerydiagnosticdelay
VIChospital2018-05-28

Finding into death of Kevin Patrick O'Keeffe

82y · Male·Cardiomegaly, myocardial fibrosis and ischaemic coronary artery disease in the c…

An 82-year-old man with extensive comorbidities underwent colonoscopy with argon plasma coagulation (APC) for bleeding angiodysplasia. Prolonged activation intervals during the final third of the procedure caused full-th…

gastroenterologysurgeryproceduralcommunicationnoradrenaline
NSWhospital2018-05-22

Inquest into the death of TM

5y · Male·complications of blunt force injury to the head

A 5-year-old boy died from complications of blunt force head injury sustained on 19-20 March 2010. He presented to a rural hospital unresponsive, with the initial account not mentioning head trauma. The attending doctor …

paediatricsemergency medicinediagnosticdelaymannitol
QLDhospital2018-05-04

LM - Non-inquest findings

1y · Female·Sepsis (Group A Streptococcus)

A nearly 16-month-old girl died from Group A Streptococcal sepsis after presenting to a regional private hospital emergency department. She had been seen multiple times by different GPs in the preceding weeks with viral …

general practiceemergency medicinediagnosticdelaymupirocin
ACThospital2018-04-26

AN INQUEST INTO THE DEATH OFJOHN BELL

71y · Male·cardiac arrest due to hyperkalemia due to acute on chronic renal failure, with r…

John Bell, a 71-year-old man with history of bowel cancer, ischaemic heart disease, and chronic renal failure, underwent elective ileostomy reversal surgery. He died from cardiac arrest due to hyperkalemia and metabolic …

surgerynephrologydiagnosticsystem
NThome2018-04-06

Inquest into the death of Asera aka Ezra Young

70y · Male·blunt force head injury (operated)

A 70-year-old Torres Strait Islander man died from blunt force head injury sustained when police forcibly woke and directed him to leave a private residence where he was sleeping. Police lacked legal powers to intervene:…

neurosurgeryemergency medicineproceduralcommunicationalcohol
TAShome2018-04-03

Coroner's Finding: Scott, Douglas Ian

81y · Male·Oxygen deprivation and carbon dioxide toxicity in a person with chronic respirat…

Douglas Ian Scott, an 81-year-old with emphysema, died from oxygen deprivation and carbon dioxide toxicity after smoking while using a home oxygen concentrator. He had been discharged from hospital with clear written and…

respiratory medicineemergency medicine
SAhospital2018-03-29

Coroner's Finding: BUTSON Graham Joseph

81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…

Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass w…

orthopaedic surgerygeneral medicinesystemwarfarin
VIChospital2018-03-29

Finding into death of Roy Irvin Dorner

64y · Male·Complications of redo thoracotomy/aortic valve replacement in a man with ischaem…

A 64-year-old physician with significant cardiac history (prior CABG, pacemaker, congestive failure, and newly severe aortic stenosis) underwent redo thoracotomy for aortic valve replacement. During sternal re-entry, the…

cardiothoracic surgerycardiology
TAShospital2018-03-26

Coroner's Finding: Russell; Patricia Joy

74y · Female·empyema/sepsis complicating oesophageal perforation following a complicated elec…

Mrs Russell, a 74-year-old woman with diabetes, obesity, COPD and coronary disease, underwent elective hernia repair in November 2016 at a regional hospital. An unexpected colon tumour was removed during surgery. She sub…

surgeryanaesthesiadiagnosticdelay
WAhospital2018-03-22

Inquest into the Death of Steven John COLLOFF

47y · Male·Organ failure following use of synthetic cannabinoids and consequent hyperthermi…

A 47-year-old man died from organ failure following synthetic cannabinoid use and consequent heat stroke. After smoking synthetic cannabinoids (AB-CHMINACA and 5F-AMB), he became confused and dehydrated in a hot environm…

toxicologyintensive careab-chminaca
WA2018-03-08

Inquest into the Death of Moses SOKIRI

31y · Male·bronchopneumonia and hypoxic brain injury following ligature compression of the …

31-year-old Moses Sokiri died on 26 October 2014 from bronchopneumonia and hypoxic brain injury following suicide by hanging at Greenwood train station on 12 October 2014. The deceased was in acute mental health crisis w…

psychiatryemergency medicinecommunicationsystemvenlafaxine
WAhospital2018-03-07

Inquest into the Death of William Scott BARTLETT

36y · Male·hypoxic brain injury and myocardial ischaemia following cardiac arrest during re…

A 36-year-old man with methylamphetamine intoxication was restrained by civilians and police following a property damage incident. He experienced cardiac arrest during restraint and died from hypoxic brain injury and myo…

emergency medicineintensive caremethamphetamine
SAhospital2018-02-29

Coroner's Finding: EVANS Wendy Marion

76y · Female·end-stage liver failure with encephalopathy due to hepatic cirrhosis

Wendy Marion Evans, aged 76, died from end-stage liver failure with encephalopathy due to hepatic cirrhosis. She presented with acute psychosis in February 2015 and was found to have extensive cerebrovascular disease, se…

psychiatryhepatology
TAShospital2018-02-28

Coroner's Finding: Patmore, Jason

44y · Male·haemorrhagic stroke complicating anticoagulation and intravenous antibiotic ther…

Jason Lee Patmore, aged 44, died from a haemorrhagic stroke that developed as a complication of anticoagulation and intravenous antibiotic therapy given for a right upper arm deep vein thrombosis acquired during hospital…

trauma surgeryneurosurgery
VIChospital2018-02-28

Finding into death of Samuel Carl Johansen

36y · Male·Multi-organ failure complicating injecting drug use

A 36-year-old man with a 13-year history of schizophrenia and substance abuse was admitted involuntarily to a psychiatric unit on 15 September 2012 after community deterioration. He improved over several weeks and was tr…

psychiatryintensive carecommunicationdelayheroin
VIChospital2018-02-26

Finding into death of Louis Oliver Tate

13y · Male·Malignant hyperthermia due to a reaction to an anaesthetic agent administered to…

Louis Tate, a 13-year-old with known allergies to cow's milk, raw egg, peanuts and tree nuts, died following anaphylaxis to breakfast provided in hospital. Despite reasonable medical management of the anaphylactic reacti…

paediatricsemergency medicinesystemcommunicationadrenaline
NSWhome2018-02-23

Inquest into the death of Yongxing Wang

79y · Male·hypoxic brain injury due to cardio-respiratory arrest caused by opioid toxicity

Yongxing Wang, 79, died from hypoxic brain injury caused by opioid toxicity from combined morphine and oxycodone. After a minor back injury on 21 August, he received a cortisone injection on 22 August with complications.…

general practiceradiologymedicationcommunicationmorphine
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