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SAhome2016-05-05

Coroner's Finding: MITTON Rodney Lyle

63y · Male·coronary artery thrombosis

A 63-year-old man with complex medical and psychiatric history died of coronary artery thrombosis while on authorized leave from psychiatric admission. He had severe triple-vessel coronary artery disease with acute throm…

psychiatrycardiologyolanzapine
SAhospital2015-09-22

Coroner's Finding: HEWLETT Betty Lorraine

92y · Female·community acquired pneumonia on a background of end stage chronic obstructive ai…

Mrs Betty Hewlett, 92, died of community-acquired pneumonia on a background of end-stage COAD. She was admitted to hospital in late December 2012 with health deterioration and malnutrition (38kg). She developed acute psy…

psychiatrygeneral medicineprednisolone
SAhospital2015-08-13

Coroner's Finding: DICKERSON Alexander Charles

79y · Male·multi-organ failure due to voluntary starvation on a background of severe depres…

A 79-year-old man died from multi-organ failure secondary to voluntary starvation in the context of severe depression following his wife's death. He was admitted after police found him malnourished following 30 days of i…

psychiatrygeneral medicine
SAhospital2015-08-13

Coroner's Finding: ABINETT Murray Lawrence

81y · Male·Aspiration pneumonia complicating end stage fronto-temporal dementia on a backgr…

Murray Lawrence Abinett, aged 81, died of aspiration pneumonia complicating end-stage fronto-temporal dementia with chronic obstructive lung disease, ischaemic heart disease and chronic renal failure. He was detained und…

psychiatrygeriatric medicinediagnosticrisperidone
SAhospital2014-11-28

Coroner's Finding: BLAIN Kathleen Olive Florence

79y · Female·acute myocardial infarction and acute pulmonary oedema

A 79-year-old woman with stroke and cardiac history was admitted for rehabilitation but developed treatment-resistant depression. Despite comprehensive multidisciplinary management including medication trials (mirtazapin…

psychiatrycardiologymirtazapine
SAhospital2014-11-28

Coroner's Finding: HOGAN Constance Mary

73y · Female·general inanition due to dysphagia on a background of multiple neurological and …

A 73-year-old woman with bipolar disorder, alcohol abuse history, and multiple medical comorbidities presented with stroke-like symptoms in March 2012. Neuroimaging was unrevealing. She was detained under the Mental Heal…

neurologypsychiatry
SAhospital2014-05-19

Coroner's Finding: SGAMBATO Raffaele

84y · Male·malnutrition in conjunction with heart, liver and kidney failure

An 84-year-old man with severe dilated cardiomyopathy, atrial fibrillation, chronic renal failure, and behavioural disturbance was admitted to Royal Adelaide Hospital following a fall. He displayed acute psychiatric symp…

cardiologypsychiatrymorphine
SAaged care2014-04-17

Coroner's Finding: WERNER Cynthia Joy

76y · Female·colchicine toxicity

A 76-year-old woman with gout died from colchicine toxicity after being prescribed 500µg three times daily on 9 December 2010 for an acute attack. She developed diarrhoea from 15 December and died on 19 December with a p…

general practicegeriatric medicinemedicationsystemcolchicine
SAaged care2014-03-21

Coroner's Finding: MORGAN Beryl Jean

73y · Female·pneumonia and renal failure with hyperthermia

Beryl Jean Morgan, 73-year-old aged care resident, died from pneumonia and renal failure with hyperthermia after a brief hospital admission. She had been prescribed haloperidol for behavioural problems; while neuroleptic…

general practicegeriatric medicinediagnosticcommunicationhaloperidol
SAhospital2014-02-14

Coroner's Finding: RYAN John William and WALTON Patricia Dawn

Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…

Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…

anaesthesiaorthopaedic surgerydiagnosticcommunicationmorphine
SAhospital2013-09-19

Coroner's Finding: HOCKING Robert Nicholas

67y · Male·aspiration pneumonia with contributing chronic schizophrenia

Robert Nicholas Hocking, a 67-year-old man with treatment-resistant chronic schizophrenia, died from aspiration pneumonia during his final hospitalization at Royal Adelaide Hospital. He was a long-term inpatient at Glens…

psychiatrygeneral medicineolanzapine
SAhospital2013-08-19

Coroner's Finding: HUNT William Edward

62y · Male·chronic congestive cardiac failure due to severe aortic valve stenosis and incom…

William Edward Hunt, aged 62, a life-sentenced prisoner, died from chronic congestive cardiac failure due to severe aortic valve stenosis and cardiomyopathy. His severe aortic stenosis was identified in 2003, but surgica…

cardiologycardiothoracic surgerydelaycommunicationfurosemide
SAhospital2012-06-18

Coroner's Finding: GRIPTON William John

62y · Male·multi organ failure due to atypical pneumonia

William Gripton, 62 years old with post-polio syndrome, presented to Kangaroo Island Hospital with upper respiratory tract infection that progressed to atypical pneumonia causing multi-organ failure and death. Critical c…

general medicineintensive carediagnosticcommunicationamoxicillin
SAhome2012-05-09

Coroner's Finding: PENNIALL David

24y · Male·neck compression due to hanging

A 24-year-old man with depression and anxiety died by hanging in March 2009, three weeks after hospital discharge following an overdose. Critical clinical lessons emerge: (1) discharge summaries from psychiatric admissio…

psychiatrygeneral practicecommunicationdelayvenlafaxine
SAhospital2011-12-07

Coroner's Finding: LANGHANS Doris Merle

89y · Female·acute renal failure with severe electrolyte disturbance due to sigmoid volvulus …

An 89-year-old woman with severe vascular dementia died from acute renal failure due to sigmoid volvulus while detained under the Mental Health Act. She was admitted to hospital for management of aggressive behaviour sec…

psychiatrygeneral medicine
SAhospital2011-12-02

Coroner's Finding: BINCH Joyce

82y · Female·acute pyelonephritis complicating base of bladder malignancy

Joyce Binch, 82, died of acute pyelonephritis from bladder malignancy while detained under mental health legislation. She was admitted with urinary tract infection, anaemia, acute renal failure, and acute exacerbation of…

psychiatrygeneral medicinerisperidone
SAhospital2011-09-23

Coroner's Finding: ANDERSON Rosemary Joy

56y · Female·multi-organ failure due to anorexia nervosa

A 56-year-old woman with a long history of anorexia nervosa and a BMI of 10.3 died from multi-organ failure after admission to hospital. She was found on her bedroom floor, dehydrated and malnourished, and was involuntar…

psychiatryintensive care
SAhospital2011-09-23

Coroner's Finding: HISCOCK Stephen West

90y · Male·aspiration pneumonia complicating community acquired pneumonia

A 90-year-old man died of aspiration pneumonia complicating community-acquired pneumonia while detained under the Mental Health Act following a suicide attempt. He presented with a sternal fracture and pneumonia, and was…

psychiatrygeneral medicine
SAhospital2011-08-03

Coroner's Finding: GILL Dennis William

72y · Male·acute leukaemia on a background of ischaemic heart disease

Dennis William Gill, a 72-year-old man serving a suspended home detention sentence, died of acute leukaemia on a background of ischaemic heart disease after admission to Ashford Hospital in August 2009. He had significan…

haematologycardiology
SAhospital2011-06-22

Coroner's Finding: TRENGROVE Ian

81y · Male·Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with co…

An 81-year-old man died from retropubic and retroperitoneal haemorrhage complicating pelvic fractures sustained in a fall at church. He was on warfarin for atrial fibrillation with an excessive INR of 4.6 at the time of …

emergency medicinegeneral medicinediagnosticcommunicationwarfarin

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