Coronial

81 results for metabolic disease

NSW2023-07-21

Inquest into the death of Reuben Button

34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…

Reuben Button, a 34-year-old Aboriginal man, died in custody from ischaemic heart disease secondary to coronary atherosclerosis. During his 5-year imprisonment, his weight increased from 86kg to …

psychiatrygeneral practicediagnosticsystembuvidal
VIChospital2025-01-29

Finding into death of Amir Mohammad Iran

2y · Male·Hyaline membrane disease and pneumonia in the setting of pneumothorax

…h respiratory distress at 11 hours of life. A capillary blood gas at 1:14pm showed mixed respiratory and metabolic acidosis indicating decompensation, but this was not recognized or escalated in the medical notes. The i…

neonatologyobstetricsdiagnosticdelaysurfactant
VIChospital2012-02-06

Finding into death of David Crisfield

43y · Male·Septic shock from streptococcus pneumoniae sepsis arising from streptococcus pne…

David Crisfield, a 43-year-old immunosuppressed patient with COPD on Crohn's disease therapy, died from streptococcus pneumoniae septic shock. He presented to a rural hospital ED on 6 Novemb…

emergency medicinegeneral practicediagnosticcommunicationsalbutamol
VIChospital2018-06-14

Finding into death of Ian John Gilbert

77y · Male·Complications of methotrexate toxicity in a man with chronic renal impairment, c…

A 77-year-old man with chronic kidney disease, COPD, and mild cardiac failure died from methotrexate toxicity after a GP prescribed it at an inappropri…

general practicepharmacydiagnosticmedicationmethotrexate
NSWcustodial setting (correctional facility) with death at hospital2025-07-23

Inquest into the death of James Cunneen

60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…

James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a b…

general practiceinfectious diseasesdiagnosticmedicationpantoprazole
NTmental health2025-02-14

Inquest into the death of Pukumani

47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…

Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…

psychiatryemergency medicinediagnosticcommunicationketamine
WAmental health2021-10-22

Inquest into the Death of Russell David BROCKLISS

38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…

Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute car…

psychiatryemergency medicinedelaysystemrisperidone depot
VIChospital2012-08-24

Finding into death of Cameron Yeates

31y · Male·Acute colonic pseudo-obstruction; death certificate amended to 'unascertained' -…

Cameron Yeates, a 31-year-old man with intellectual disability (IQ 64) and longstanding gastrointestinal issues, died from acute colonic pseudo-obstruction with underlying malnourishment. Key clinical lessons: (1) severe…

gastroenterologygeneral practicecommunicationsystemwarfarin
VIChome2014-05-15

Finding into death of Georgia Susan Cheal

31y · Female·Pneumonia; combined drug toxicity (including marijuana), smoking, pathological o…

Georgia Cheal, a 31-year-old with complex medical history including chronic pain, major depression, and obesity, died from pneumonia exacerbated by combined drug toxicity from multiple prescription medications, cannabis,…

general practicepsychiatrycommunicationsystemoxycodone
VIChome2023-07-27

Finding into death of Loris Lesley O'Meara

75y · Female·Renal failure and ketoacidosis in a woman with chronic alcoholism and type 2 dia…

A 75-year-old woman with type 2 diabetes and chronic alcoholism died from renal failure and ketoacidosis at home. She was isolated, dependent on her elderly husband for care, and living in squalor. Over 20 disclosures of…

general practicegeriatric medicinecommunicationsystemmetformin
VIChome2025-11-18

Finding into death of JZA

65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …

A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…

geriatric medicineinfectious diseasessystemcommunicationpholcodine
VIChospital2023-02-22

Finding into death of Christine Ann Stephen

67y · Female·Intra-abdominal sepsis complicating an anastomotic leak following elective surge…

A 67-year-old woman died from intra-abdominal sepsis following an anastomotic leak from elective colorectal surgery to repair a vesico-colic fistula. The initial surgery on 1 November 2017 was appropriately performed, an…

colorectal surgeryintensive carecommunicationdelaynoradrenaline
QLDhospital2014-01-31

George, Lynda Margaret - Non-inquest findings

60y · Female·Peritonitis due to anastomotic leak following subtotal colectomy for treatment o…

60-year-old woman died from septic shock due to anastomotic leak following subtotal colectomy for synchronous bowel cancers. Early postoperative bronchospasm complicated clinical assessment, leading focus on respiratory …

general surgerycolorectal surgerydiagnosticcommunication
QLDcommunity2019-06-10

Coolwell, Shaun Charles

33y · Male·cardiorespiratory arrest during restraint, involving a predisposition to cardiac…

33-year-old Indigenous man died following police restraint and inappropriate midazolam administration during an acute drug-induced behavioural disturbance. Mr Coolwell sustained injuries while in acute methamphetamine-in…

emergency medicinepharmacologydiagnosticcommunicationmethamphetamine
VICaged care2026-01-19

Finding into death of Kevin Thomas Maloney

39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…

Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…

psychiatryaddiction medicinecommunicationsystemheroin
WAhospital2022-03-28

Inquest into the Death of Morgan John EDWARDS

31y · Male·Complications in association with intestinal volvulus

31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elev…

emergency medicinegastroenterologydiagnosticcommunication
NSWhospital2025-11-17

Inquest into the death of Brooke Tiddy

32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…

A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…

bariatric surgeryanaesthesiadiagnosticcommunicationsevoflurane
WAhospital2023-02-22

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)

…found the death possibly preventable with timely recognition, though the extreme bacterial load and rapid disease progression meant survival was unlikely even with earlier intervention.

emergency medicinepaediatricsdiagnosticcommunication
NSWhospital2019-05-14

Inquest into the death of Shaun BELL

4y · Male·Peritoneal sepsis caused by a perforated duodenal ulcer

A 4-year-old boy with significant global developmental delay and non-verbal communication died from peritoneal sepsis caused by a perforated duodenal ulcer. Presentation included lethargy, poor oral intake, low haemoglob…

emergency medicinepaediatricsdiagnosticcommunication
SAhospital2011-03-28

Coroner's Finding: ALLAN Vera

81y · Female·Severe cardiogenic shock complicating cardiac surgery

An 81-year-old woman died of severe cardiogenic shock following elective aortic valve replacement complicated by intraoperative haemodynamic instability and inadequate postoperative ICU management. The surgery involved e…

cardiothoracic surgeryanaesthesiamedicationcommunicationadrenaline

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