Coronial

154 results for malnutrition

VIChome2023-01-30

Finding into death of Veronica Nelson

37y · Female·complications of withdrawal from chronic opiate use and Wilkie Syndrome in the s…

…final intercom call around 4am and was found deceased at 7:50am, with post-mortem examination revealing malnutrition (BMI 12.9), gastric dilation, and electrolyte disturbances from withdrawal and/or Wilkie Syndrome. Clin…

general practiceaddiction medicinediagnosticsystembuprenorphine/naloxone
VIChospital2021-12-10

Finding into death of Ronald Jelbert

90y · Male·Sepsis in the setting of cachexia in a man with multiple comorbidities

Ronald Jelbert, a 90-year-old man with moderate intellectual disability living in a disability group home, was admitted to hospital on 21 December 2019 with sepsis suspected secondary to urinary tract infection, colonic …

emergency medicinegeneral medicine
NSW2018-05-30

Inquest into the death of Abduelaziz Omerhaj

36y · Male·undetermined (possibly ethylene glycol poisoning; possibly natural cause such as…

A 36-year-old man with acute psychotic illness absconded from Ryde Hospital Emergency Department on 3 August 2013 after refusing oral antipsychotic medication. He evaded police efforts to locate him and was found dead in…

psychiatryemergency medicinecommunicationproceduralolanzapine
VIChospital2025-02-26

Finding into death of CFT

78y · Female·Bronchopneumonia

…e, carers, GP, OPA) documented concerns about neglect from 2017 onwards including poor continence care, malnutrition, weight loss, inadequate hygiene, and failure to attend medical appointments. Despite a VCAT guardiansh…

geriatric medicinegeneral practicediagnosticsystem
ACThospital2026-05-12

Inquest into the death of Mr Deleman

69y · Male·peritonitis due to perforated bowel

…l pattern of early mortality in people with severe mental illness combined with physical comorbidities, malnutrition, and substance abuse.

emergency medicinegastroenterologypaliperidone
TAShospital2017-06-16

Coroner's Finding: Baldock, Andrea Eileen

46y · Female·combined effects of aspiration pneumonia due to gastroparesis following sleeve g…

A 46-year-old woman died from aspiration pneumonia due to gastroparesis following sleeve gastrectomy, complicated by ischaemic heart disease. Post-operative recovery was beset with persistent vomiting, dehydration, and e…

general surgerygastroenterologysystemdelay
WAhospitalJuly 2023

Inquest into the Death of Lincoln Arthur CAMPBELL

52y · Male·end-stage throat cancer

Lincoln Campbell, a 52-year-old Aboriginal man with terminal throat cancer, disappeared from Kununurra Hospital on 24 December 2005 while receiving palliative care. He had a PEG feeding tube, required regular morphine an…

oncologypalliative caremorphine
SAhospital2016-09-01

Coroner's Finding: CALLAGHAN Brian Francis

79y · Male·Multi-organ failure due to pneumonia and bleeding duodenal ulcer complicating su…

A 79-year-old man with ischaemic heart disease and dementia fell at home, sustaining a left hip fracture requiring surgery. Post-operatively, he developed hospital-acquired pneumonia, upper gastrointestinal bleeding from…

general surgeryorthopaedic surgery
VIChospital2014-11-26

Finding into death of Ming Shan Yuan

88y · Male·Tuberculous pneumonia in the setting of multiple rib fractures, osteoporosis and…

Ming Shan Yuan, an 88-year-old man with osteoporosis and cachexia, died from tuberculosis pneumonia precipitated by multiple rib fractures. He suffered elder abuse and neglect by his primary carer daughter over months be…

emergency medicinegeriatric medicinediagnosticdelayantibiotics
VICaged care2023-03-22

Finding into death of Margaret Alice Cook

88y · Female·Complications of a stage 3 sacral pressure ulcer in a woman with dementia

Margaret Alice Cook, an 88-year-old woman with end-stage dementia, died from complications of a stage 3 sacral pressure ulcer at a palliative care unit. She had resided at Crofton House Supported Residential Services (SR…

geriatric medicinegeneral practicesystemcommunicationflucloxacillin
SAhospital2008-06-06

Coroner's Finding: AUSTIN Grant Aaron

29y · Male·aspiration pneumonia complicating acute and chronic Wernicke's encephalopathy an…

Grant Austin, a 29-year-old man with intellectual disability and morbid obesity, died from aspiration pneumonia complicating Wernicke's encephalopathy. He presented with prolonged refusal to eat and drink from December 2…

general medicinepsychiatrycommunicationdiagnostictrimethoprim
NSWhospital2019-06-14

Inquest into the death of Melissa King

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

…halopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraemia, and alcohol-related liver disease. Expert review ide…

intensive careendocrinologydiagnosticcommunicationglycoprep
TAShome2025-08-05

Coroner's Finding: Iliev, Patricia

57y · Female·starvation due to insufficient food intake

Patricia Iliev, a 57-year-old woman, died from starvation after progressively restricting her food intake over months while immobilised by chronic back pain. She had a gastrointestinal stromal tumour and advanced lung di…

general practicepsychiatrysystemdelayaspirin
VIChome2020-01-14

Finding into death of H B

8y · Female·Aspiration pneumonia in a child with an epileptic encephalopathy and extreme cac…

HB, age 8 years 10 months, died from aspiration pneumonia with extreme cachexia (BMI 7). She had severe cerebral palsy, epilepsy (Lennox-Gastaut syndrome), and was entirely dependent on PEG tube feeding. Between January …

paediatricsneurologydiagnosticdelaylevetiracetam
WAhospital2023-01-11

Inquest into the Death of Colin Albert WINTER

71y · Male·End-stage chronic obstructive pulmonary disease and atherosclerotic heart diseas…

Colin Albert Winter, a 71-year-old prisoner who died from end-stage COPD and atherosclerotic heart disease, received comprehensive medical care during 33 years of incarceration at Casuarina Prison. Key clinical lessons i…

respiratory medicinecardiologycommunicationsystem
NSWhome2010-08-26

Coroner's Finding: Kate Therese Bugmy

26y · Female·Streptococcal Sepsis resulting from Skin Ulceration and complications of Cerebra…

Kate Therese Bugmy, a 26-year-old woman with cerebral palsy, epilepsy, and intellectual disability, died on 28 June 2007 of Streptococcal sepsis from infected pressure ulcers. She was cared for at home by her mother Daph…

general medicineemergency medicinesystemcommunication
QLDaged careNew2026-06-09

Non-inquest findings into the death of Mr B (1 of 3 linked pressure injury cases)

86y · Male·Multiorgan failure due to neurological failure due to Alzheimer's dementia

An 86-year-old man with advanced Alzheimer's dementia developed multiple pressure injuries while residing in aged care. A Stage 1 sacral pressure wound rapidly deteriorated to Stage 4 over two weeks despite appropriate a…

geriatric medicinepalliative carecommunicationsystem
SAhospital2019-10-23

Coroner's Finding: GIBSON Anthony Stephen

53y · Male·aspiration pneumonia on a background of oesophageal cancer and ischaemic heart d…

Anthony Stephen Gibson, aged 53, died in hospital from aspiration pneumonia secondary to oesophageal cancer and ischaemic heart disease. He was serving a prison sentence and was shackled to his bed throughout most of his…

gastroenterologygeneral surgerycommunicationsystem
SAhospital2009-09-11

Coroner's Finding: LANGFORD Peter

64y · Male·hospital-acquired pneumonia on a background of end-stage cryptogenic liver cirrh…

Peter Langford, aged 64, died of hospital-acquired pneumonia complicated by end-stage cryptogenic liver cirrhosis after a 43-day admission to Flinders Medical Centre. He presented with severe cellulitis requiring amputat…

gastroenterologygeneral medicinesystemlactulose
NThome2014-09-01

Inquest into the death of Baby C

0y · Female·undetermined (chronic malnutrition ruled out; possible dehydration with electrol…

…in final week). She died on 9 January 2013 at 6 months old. Autopsy findings were inconclusive; chronic malnutrition was ruled out by expert evidence of consistent pre-hospital growth. The coroner could not determine a p…

paediatricsneonatologydelay
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