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NT2017-11-21

Inquest into the death of Dale Walkinshaw

23y · Male·self-inflicted hanging

Dale Walkinshaw, a 23-year-old male, died by self-inflicted hanging in a police caged vehicle while being transported to hospital for medical clearance following his arrest for drink-driving. He used his bootlace, attach…

emergency medicineintensive caresystemdelayalcohol
VIChospital2017-11-20

Finding into death of Graeme Harold Griffiths

65y · Male·Severe neutropenic sepsis and multi-organ failure secondary to severe mucositis …

A 65-year-old man with stage 3 rectal cancer died from severe neutropenic sepsis and multi-organ failure secondary to probable dihydropyrimidine dehydrogenase (DPD) deficiency when treated with capecitabine chemotherapy.…

oncologyradiation oncologydelaycapecitabine
SAhospital2017-11-17

Coroner's Finding: FREDERICK Geoffrey Lachlan Hogarth

60y · Male·End stage renal failure

Geoffrey Frederick, aged 60, died of end-stage renal failure while subject to a Mental Health Act order at Royal Adelaide Hospital. He had schizophrenia and chronic kidney disease requiring dialysis, but repeatedly remov…

nephrologypsychiatry
VIChospital2017-11-09

Finding into death of Emma Kate McGrath

19y · Female·Meningococcal septicaemia

Emma McGrath, a 19-year-old nursing student, died from meningococcal septicaemia caused by the W strain after presenting to the ED with a 12-hour history of vomiting, diarrhoea, abdominal pain and fever. The atypical pre…

emergency medicineintensive careparacetamol
VIC2017-10-31

Finding into death of Andrew John Harman

49y · Male·Complications of heatstroke; Hyperthermia

A 49-year-old man died from heatstroke and hyperthermia while on a guided dirt bike tour in Hawaii. He consumed significant alcohol the previous day, then engaged in strenuous physical activity in warm, humid conditions …

emergency medicineintensive caredelay
QLDhospital2017-10-23

Non Inquest Findings TO

73y · Male·Sepsis (gram-negative septic shock) secondary to complications of selective inte…

A 73-year-old man died from gram-negative septic shock following selective internal radiation therapy (SIRT) for metastatic gastric cancer. He had previously undergone a Whipple procedure in 2014, which creates a direct …

radiologyemergency medicinediagnosticmedication
QLDhospital2017-10-17

SWK - Non inquest findings

78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…

78-year-old Jehovah's Witness died from multi-organ failure secondary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple c…

spinal surgeryorthopaedic surgeryproceduraldiagnosticaramine
QLDhospital2017-10-06

Parsons, Ann

59y · Female·Global cerebral oedema due to hypoxic cerebral ischaemia following cardiac arres…

59-year-old woman admitted with newly diagnosed grade 4 glioblastoma underwent surgery 16 days later after delays during consultant's planned leave. Post-operative complications included ischaemic stroke confirmed on ima…

neurosurgeryintensive carediagnosticcommunicationdexamethasone
TAS2017-10-05

Coroner's Finding: Patmore, Jason - Decision as to Inquest

44y · Male·traumatic subarachnoid haemorrhage and diffuse brain injury sustained in a bicyc…

A 44-year-old experienced cyclist died from traumatic subarachnoid haemorrhage and diffuse brain injury sustained in a bicycle crash on 29 July 2015. The coroner concluded after thorough investigation that Mr Patmore los…

emergency medicineintensive care
WAhospital2017-09-29

Inquest into the Death of Jared Charles OLSEN

41y · Male·Fulminant sepsis (Klebsiella pneumoniae) with multi-organ failure complicating s…

A 41-year-old man with newly diagnosed severe Crohn's colitis was prescribed 6-mercaptopurine (6-MP) after only 5 days of hospital treatment. He had a homozygous TPMT gene deficiency (present in ~0.3% of population) that…

gastroenterologyintensive carediagnosticsystem6-mercaptopurine
TAShospital2017-09-25

Coroner's Finding: Willox, Brian William

81y · Male·pneumonia complicating fracture of the neck of the right femur sustained in a fa…

An 81-year-old man with multiple chronic conditions including dementia, ischaemic heart disease, emphysema, and hypertension sustained a fractured right femoral neck from a fall at an aged care facility. He underwent sur…

orthopaedic surgerygeneral medicine
QLDhospital2017-09-20

Mr TAM - Non-inquest findings

62y · Male·Multi-organ infarctions (brain, kidneys, heart) resulting from thromboemboli sec…

Mr TAM, a 62-year-old man with multiple cardiac conditions, died from multi-organ infarction secondary to an atrio-oesophageal fistula that developed after radio-frequency ablation for atrial fibrillation. The fistula is…

cardiologycardiothoracic surgerycommunicationsystem
WAhome2017-09-15

Inquest into the Death of Mary Josephine Van der WALT

28y · Female·ligature compression of the neck

Mary Van Der Walt, a 28-year-old with depression, anxiety, and borderline personality disorder, died by hanging on 21 April 2014. Two police officers responding to her initial '000' call found her unresponsive and pulsel…

emergency medicineintensive carediagnosticcommunicationdesvenlafaxine
VIChome2017-09-11

Finding into death of Nancy May Budge

83y · Female·Gunshot wound to the head

Nancy May Budge, 83 years old, died from a gunshot wound to the head on 3 November 2016. She had extensive cardiac history including multiple valve replacements, pacemaker insertion, and congestive heart failure diagnose…

cardiologyintensive care
VIChospital2017-09-11

Finding into death of Baby Minahil Bhatti

0y · Female·Septic shock with multi-organ failure and probable meningitis, secondary to non-…

Baby Minahil Bhatti, a five-month-old with congenital non-compaction cardiomyopathy, died from septic shock with multi-organ failure and probable meningitis. She presented to Royal Children's Hospital on 27 July 2016 wit…

cardiologyintensive care
TAScommunity2017-09-08

Coroner's Finding: Holmes, David Scott

51y · Male·Hypoxic/ischaemic brain damage following head and chest injuries sustained in a …

David Scott Holmes, a 51-year-old truck driver, died from hypoxic-ischaemic brain damage following a truck rollover on 7 April 2016. He suddenly veered off the Midlands Highway near Bagdad, Tasmania, after experiencing a…

cardiologyintensive care
NSW2017-08-31

Inquest into the death of David WOTHERSPOON

31y · Male·Hypoxic encephalopathy caused by neck compression due to hanging

David Wotherspoon, a 31-year-old Aboriginal man with schizophrenia, died from hypoxic encephalopathy following hanging in a prison mental health unit. Despite being psychotic and refusing medication, he was not transferr…

psychiatrycorrectional healthsystemcommunicationrisperidone
VIChospital2017-08-14

Finding into death of Magdalena Dorter

58y · Female·Haemorrhagic shock complicating pulmonary thromboembolism in the setting of deep…

A 58-year-old woman with obesity (BMI 38) sustained a metatarsal fracture and was treated with a below-knee plaster cast by her GP. Despite appropriate initial assessment and consultation with a haematologist regarding V…

general practicehaematologysystemletrozole
NThospital2017-08-10

Inquest into the death of Ruby Blitner

7y · Female·respiratory failure from severe scoliosis due to Murray Valley encephalitis

Ruby Blitner died from respiratory failure secondary to severe scoliosis caused by Murray Valley encephalitis acquired at age two. Her clinical course involved progressive respiratory compromise, recurrent aspiration pne…

paediatricsinfectious diseases
QLDhospital2017-07-31

Mrs NSM - Non-inquest findings

81y · Female·left haemothorax and mediastinal haemorrhage from the insertion site of the perm…

An 81-year-old woman died from haemothorax and mediastinal haemorrhage following pacemaker insertion for sick sinus syndrome. Multiple venous punctures during the procedure caused vascular injury. Critical clinical lesso…

cardiologyintensive carediagnosticcommunicationglyceryl trinitrate
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