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VIChospital2016-10-25

Finding into death of Andrew Michael ODonnell

46y · Male·Pulmonary thromboembolism complicating left calf deep venous thrombosis

A 46-year-old man presented to ED with a two-day history of left calf pain, swelling and numbness. He was triaged to Fast Track and evaluated by an emergency physician who suspected DVT but had no ultrasound available on…

emergency medicinehaematologydiagnosticenoxaparin
SAhospital2016-09-29

Coroner's Finding: MCSHANE Robert Ian

66y · Male·Multi-system failure and ischaemic gut after left nephrectomy complicated by mas…

A 66-year-old man died from multi-system failure and ischaemic bowel following laparoscopic left nephrectomy complicated by massive haemorrhage and vascular injury. During surgery for renal carcinoma, the surgeon attempt…

urologyvascular surgeryproceduralsurgical judgment
VIChospital2016-08-18

Finding into death of Susan Bourke

49y · Female·Widespread small and large bowel, splenic and hepatic infarction secondary to se…

Susan Bourke, a 49-year-old woman, died from widespread small and large bowel infarction secondary to severe aortic atherosclerosis causing critical stenosis of the superior mesenteric and coeliac arteries. She presented…

emergency medicineradiologydiagnosticcommunication
VIChospital2016-04-14

Finding into death of Kelly Maree Richards

29y · Female·Exsanguination post tubal ligation procedure

A 29-year-old woman died from exsanguination following an iatrogenic injury during elective laparoscopic tubal ligation at a regional hospital. A vascular injury to the right external iliac artery occurred during the pro…

general surgerygynaecologyproceduralcommunicationpacked red blood cells
SAhospital2015-08-13

Coroner's Finding: HILL John George Charles

71y · Male·acute pyelonephritis with contributing ischaemic heart disease

A 71-year-old male prisoner died from acute pyelonephritis with contributing ischaemic heart disease at Flinders Medical Centre. He had advanced metastatic gastric cancer diagnosed in February 2011 after presenting with …

colorectal surgerygeneral surgery
VIC2015-05-29

Finding into death of Ignac Lecek

68y · Male·Ischaemic small and large intestine complicating cardiogenic shock in the settin…

Ignac Lecek, 68, with hypertension and gout, collapsed in custody and died of ischaemic bowel complicated by cardiogenic shock in the setting of ischaemic heart disease. He complained of feeling ill on 2 October while in…

emergency medicinevascular surgerycommunicationsystemdiazepam
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
SA2014-11-28

Coroner's Finding: MAYGER John Christopher

58y · Male·Ischaemic and hypertensive heart disease

John Christopher Mayger, aged 58, died of ischaemic and hypertensive heart disease while in custody at Adelaide Pre-release Centre. He had a significant cardiac history including two previous myocardial infarctions with …

cardiologyemergency medicinerosuvastatin
VIChospital2014-11-17

Finding into death of Allan Phipps

76y · Male·exsanguination secondary to pulmonary aortic fistula and thoracic aorta aneurysm…

Allan Phipps was a 76-year-old man with a known thoracic aortic aneurysm and severe depression admitted to Austin Hospital in October 2012 for unstable angina and depression management. His aneurysm, discovered in March …

vascular surgerycardiologysystemdelayquetiapine
VIChospital2014-10-02

Finding into death of Penrin John Maxworth Halliday

60y · Male·Ischaemic gut secondary to superior mesenteric artery dissection complicating in…

A 60-year-old man with severe coronary artery disease presented with acute myocardial infarction, requiring emergency stenting and subsequent bypass surgery. An intra-aortic balloon pump (IABP) was inserted for haemodyna…

cardiologycardiothoracic surgery
QLDhospital2014-09-01

SG - Non-inquest findings

68y · Female·Haemorrhage secondary to right subclavian artery lacerations sustained during ce…

A 68-year-old woman died from massive blood loss following inadvertent puncture of the right subclavian artery during central venous line insertion. The anaesthetist used anatomical landmarks without ultrasound after an …

anaesthesiageneral surgeryheparin
VIChospital2014-08-27

Finding into death of Robert Vivian Hawkins

55y · Male·Multi-system failure complicating intra-operative haemorrhage due to inadvertent…

Robert Vivian Hawkins, a 55-year-old man, died from multi-system failure following inadvertent ligation of the superior mesenteric artery (SMA) during laparoscopic nephrectomy for renal cell carcinoma. Dr Jonathan Lewin …

urologygeneral surgerydiagnosticprocedural
VIChospital2014-06-20

Finding into death of Rosalie Anne King

29y · Female·Bronchopneumonia in a woman with brain injury

A 29-year-old Aboriginal woman suffered a motor vehicle collision resulting in severe multi-system injuries requiring multiple surgical interventions. Eleven days after transfer to the trauma ward, she experienced sudden…

trauma surgeryintensive care
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
SAhospital2013-09-30

Coroner's Finding: GIANNINI Pasquale

68y · Male·infarction of the small and large bowel due to superior mesenteric artery thromb…

A 68-year-old man with extensive systemic vascular disease presented with 10 days of nonspecific abdominal pain. Initial presentations at local hospital and GP were attributed to possible gallstones or gastritis based on…

general practiceemergency medicinediagnosticdelayaugmentin duo
VIChospital2013-08-15

Finding into death of William John Colhoun

71y · Male·Multi organ failure due to post-operative bleeding following endoluminal thoraci…

William Colhoun, 71, underwent complex endovascular repair of thoracic-abdominal aortic aneurysm at St Vincent's Private Hospital on 1 December 2008. He developed post-operative instability with hypotension, metabolic ac…

vascular surgeryradiologycommunication
VIChospital2013-04-12

Finding into death of Bruce John Stubbs

59y · Male·Ruptured atherosclerotic abdominal aortic aneurysm (operated)

A 59-year-old man with a non-ruptured 8cm infrarenal abdominal aortic aneurysm (AAA) presenting with acute back pain was transferred from Bendigo to Royal Melbourne Hospital at 2.13am on 22 April 2008. Despite appropriat…

vascular surgeryemergency medicinediagnosticdelaymorphine
WAhospital2013-01-17

Inquest into the Death of Aslett, Wendy May

60y · Female·Multiple organ failure following haemorrhage from penetration of the femoral art…

A 60-year-old woman died from massive retroperitoneal bleeding following coronary angiography. An Angio-Seal device was used to close the femoral artery puncture but failed to maintain seal. Post-discharge, rapid haemato…

cardiologygeneral practicediagnosticcommunicationprasugrel
VIChospital2012-11-26

Finding into death of George Albert John Hutton

73y · Male·ruptured abdominal aortic aneurysm

George Hutton, a 73-year-old man with hypertension, presented to rural emergency department with sudden onset severe abdominal pain while turning his head. Clinical findings were atypical: he appeared calm, had relativel…

emergency medicinegeneral practicediagnosticdelaycoversyl plus
VIChospital2012-09-11

Finding into death of Robert Anderson

50y · Male·Complications of right buttock necrotising fasciitis secondary to chronic right …

50-year-old male with chronic pain from jockey injuries became dependent on morphine. General practitioner prescribed intramuscular (IM) morphine for self-administration at home from 2005–2007 at doses of 120–240mg daily…

general practicepsychiatrydiagnosticmedicationmorphine sulphate

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