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QLDhospital2016-06-03

James, Kesler Lee

5y · Male·Acute bronchopneumonia and diffuse alveolar damage due to acute rheumatic cardit…

A 5-year-old boy with rheumatic heart disease and acute mitral valve regurgitation presented to Mt Isa Hospital with acute heart failure. Although initially recognised as deteriorating by the paediatrician on-call, the s…

paediatricsintensive carediagnosticcommunicationfurosemide
QLDhospital2016-03-18

McGuane, Shirley Fay - Non-inquest findings

84y · Female·Myocardial infarction

Shirley McGuane, 84, died from myocardial infarction following elective proctocolectomy. Post-operative care was deficient: chest pain on day 2 post-op with ECG showing atrial fibrillation and new right bundle-branch blo…

surgerycardiologydiagnosticcommunicationwarfarin
QLDhospital2016-02-29

Mr B - Non-inquest findings

84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…

An 84-year-old man with multiple comorbidities was prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed,…

cardiologyhaematologymedicationcommunicationrivaroxaban
QLDhospital2016-02-17

Dickinson, Rick Dudley

55y · Male·Cardiac tamponade due to ruptured aortic dissection (Type A) against a backgroun…

Rick Dickinson, a 55-year-old man, presented to St Andrew's War Memorial Hospital after experiencing severe central chest pain and lower back pain with numbness at the gym. The treating senior doctor failed to adequately…

emergency medicinepathologydiagnosticcommunicationmorphine
QLD2016-01-19

Reynolds, Michael John

55y · Male·coronary atherosclerosis

Michael Reynolds, aged 55, died of coronary atherosclerosis while incarcerated. He had suffered a myocardial infarction at age 32 and subsequently refused cardiac medications despite medical advice, a decision consistent…

cardiologyforensic medicinesodium valproate
QLD2015-11-04

Spence, John Michael

51y · Male·Combined effects of atherosclerotic cardiovascular disease and seizure activity …

John Spence, a 51-year-old man with a history of seizures, alcoholism, and severe coronary artery disease, died in a prison health centre following a seizure episode. He had ingested an extraordinarily high level of caff…

emergency medicinecardiologydiagnosticcommunicationcaffeine
QLDhospital2015-07-28

Mills, Stephen John

57y · Male·Head injury from fall; with coronary atherosclerosis and complete heart block wi…

A 57-year-old man with bipolar disorder died from head injury following a fall at Toowong Private Hospital. Critical failures in falls risk management were identified: no formal falls risk assessment was completed on adm…

psychiatryneurosurgerysystemcommunicationseroquel xr
QLDhospital2015-07-27

KS - Non-inquest findings

69y · Male·Intracerebral haemorrhage due to sepsis (Staphylococcus aureus bacteraemia), com…

A 69-year-old man with a history of myocardial infarction and atrial fibrillation presented to a rural hospital with fever, lethargy, tachycardia and elevated troponin. The treating doctor diagnosed NSTEMI based on the e…

emergency medicinecardiologydiagnosticmedicationrivaroxaban
QLDhospital2015-07-03

Apelu, Faaee - Non-inquest findings

41y · Male·Myocardial infarction secondary to coronary atherosclerosis, resulting in sudden…

A 41-year-old man with multiple cardiac risk factors (hypertension, hyperlipidemia, obesity, obstructive sleep apnoea, family history) presented with chest pain and was diagnosed with acute coronary syndrome. Coronary an…

cardiologygeneral practicediagnosticmedicationaspirin
QLDhome2015-06-30

Beckman, Seth David - Non-inquest findings

34y · Male·Drowning due to shallow water blackout

A 34-year-old man died from drowning in a residential swimming pool while practicing breath-holding with hyperventilation, a technique he had used since childhood for spearfishing competitions. The coroner concluded deat…

forensic medicineemergency medicinecommunicationsystem
QLDcommunity2015-06-12

Wilson, Brad Maxwell

49y · Male·Coronary artery thrombosis due to coronary atherosclerosis

Brad Wilson, 49, collapsed and died from acute coronary thrombosis approximately 40 minutes after police arrest at a polling booth on 7 September 2013. He had severe pre-existing triple-vessel coronary atherosclerosis, s…

cardiologyemergency medicinecannabis
QLDhospital2015-03-30

Mulhall, Terrance - Non-inquest findings

48y · Male·myocardial infarction due to ischaemic heart disease due to hypertension

A 48-year-old man died from myocardial infarction due to ischaemic heart disease and hypertension shortly after undergoing urology surgery. Critical failures in clinical communication prevented recognition of undiagnosed…

anaesthesiaurologycommunicationdiagnostictelmisartan
QLDcommunity2015-03-11

Kumar, Amit

34y · Male·The combined effects of restraint, coronary artery atherosclerosis and centripet…

A 34-year-old man died following 10 minutes of restraint by six people at a marina car park after assaulting two staff members. He had significant coronary atherosclerosis (70-75% narrowing) and centripetal obesity. Desp…

forensic medicineemergency medicineproceduralcommunicationmethadone
QLDcommunity2015-02-11

Dennis, Jerry Arthur - Non-inquest findings

17y · Male·drowning due to or as a consequence of cardiomegaly

A 17-year-old male member of a surf life saving club died by drowning during a flat-water paddle board training session in a canal. He reported feeling unwell and attempted to paddle back, but fell from his board and bec…

pathologycardiology
QLDhospital2015-01-29

Carpenter, Harold James

66y · Male·Coronary atherosclerosis with emphysema as secondary cause

Harold James Carpenter, a 66-year-old prisoner with significant comorbidities including ischaemic heart disease, emphysema, hepatitis C and possible malignancy, died from coronary atherosclerosis and emphysema. He presen…

emergency medicineorthopaedic surgeryoxycodone
QLD2014-12-17

Horace, Reynold David

51y · Male·Coronary atherosclerosis

A 51-year-old Aboriginal man with a 26-year prison history died from coronary atherosclerosis while incarcerated. He had extensive cardiac disease documented since 1996, with multiple heart attacks in 2011-2012, yet rema…

cardiologypsychiatry
QLDhospital2014-12-17

Courtney, Victor

44y · Male·End stage non-small cell lung carcinoma

Victor Courtney, aged 44, died from end-stage non-small cell lung carcinoma with hepatic metastases while incarcerated at Wolston Correctional Centre. He was diagnosed with lung cancer in November 2012 after presenting w…

oncologyrespiratory medicine
QLD2014-11-25

Peter, John Kelly

62y · Male·Congestive cardiac failure due to ischaemic heart disease

John Kelly Peter, a 62-year-old man, died in Lotus Glen Correctional Centre from congestive cardiac failure secondary to ischaemic heart disease. He had multiple chronic conditions including diabetes, hypertension, and h…

cardiologygeneral medicine
QLDhospital2014-11-04

Chettiar, Dharam Raj

82y · Male·Ischaemic cardiomyopathy resulting from coronary atherosclerosis (with previous …

An 82-year-old man with longstanding cardiac disease and renal failure died in custody from acute heart failure. He had been imprisoned for 3 years with well-documented cardiac history requiring 42 hospital transfers. In…

cardiologyemergency medicinenicorandil
QLDhospital2014-11-03

Proberts, Mark William

52y · Male·Acute coronary syndrome caused by coronary artery embolus secondary to infective…

Mark Proberts, a 52-year-old man with multiple chronic conditions (diabetes, liver disease, hypertension), died in hospital from acute coronary syndrome secondary to infective endocarditis. He was transferred from correc…

emergency medicineintensive carepenicillin

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