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NSWhospital2017-04-19

Inquest into the death of Heidi COX

58y · Female·consequences of acute subdural haemorrhage

Heidi Cox, 58, died from acute subdural haemorrhage after suffering interpersonal violence, likely at the hands of her long-term partner Karl Bingle. She was found unconscious at their residence and died in hospital. Evi…

emergency medicineintensive carequetiapine
VICpolice2017-04-10

Finding into death of Michael John Darmody

51y · Male·Combined drug toxicity (methadone and benzodiazepines) in a man with coronary an…

Michael Darmody, 51, died in police custody from combined drug toxicity in the setting of underlying coronary and cerebrovascular disease. He was remanded overnight and found unconscious at 6.01am. Key clinical lessons: …

emergency medicineintensive carecommunicationdiagnosticmethadone
QLDhospital2017-04-04

Coolwell, Bradley Karl

39y · Male·respiratory failure and cardiac arrest

Bradley Karl Coolwell, a 39-year-old Indigenous Australian with schizo-affective disorder and significant comorbidities (obesity, respiratory infection, diabetes), presented to Logan Hospital after police noted concernin…

emergency medicinepsychiatrydiagnosticcommunicationmidazolam
WAhospital2017-03-31

Inquest into the Death of Anna Maria WINTER

94y · Female·Sepsis complicating management of vulval carcinoma in an elderly woman with seve…

A 94-year-old woman with vulval carcinoma underwent suprapubic catheter insertion at a private hospital on 14 May 2014. She appeared well post-procedure with normal observations. The following day, she was transferred by…

urologyoncologycommunicationsystem
NThospital2017-03-30

Inquest into the death of Irene Magriplis

75y · Female·septic complications following surgical resection of duodenal ampullary adenoma

A 75-year-old woman died of sepsis from bile leaking into her abdomen after elective surgery to remove a pre-malignant tumour adjacent to the bile duct. The coroner found multiple preventable failures: inadequate pre-ope…

general surgeryanaesthesiadiagnosticprocedural
TAShospital2017-03-27

Coroner's Finding: Whittle, Marion Olive 2017 TASCD 114

87y · Female·cardiogenic shock and tricuspid regurgitation secondary to traumatic papillary m…

Marion Olive Whittle, aged 87, died from cardiogenic shock and tricuspid regurgitation following a motor vehicle crash on 6 January 2014. She sustained a traumatic papillary muscle laceration when the vehicle she was a p…

trauma surgeryintensive care
ACThome2017-03-23

AN INQUEST INTO THE DEATH OF PAP

55y · Male·Septicaemia due to hydronephrosis and infection

A 55-year-old man with complex medical and social problems died of septicaemia from renal infection. He had a history of cardiac disease requiring anticoagulation, alcohol dependence, depression, and chronic hoarding beh…

cardiologypsychiatrysystemcommunicationwarfarin
TAShospital2017-03-20

Coroner's Finding: Bird, Heather Mary

66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…

A 66-year-old woman died from retroperitoneal haemorrhage following anticoagulation for stroke caused by intra-arterial central venous catheter placement. The catheter was mistakenly inserted into the right carotid arter…

anaesthesiarehabilitation medicinediagnosticproceduralenoxaparin
QLDhospital2017-02-28

Paddon, Darrin Edward

51y · Male·Acute myocardial infarction due to coronary atherosclerosis

A 51-year-old man with end-stage renal disease, hepatitis C cirrhosis, endocarditis, and aortic valve disease died in custody from acute myocardial infarction. He presented with gastrointestinal bleeding, pancytopenia, a…

nephrologycardiologyaspirin
VIChospital2017-02-23

Finding into death of Goet Wo Tjoeng

71y · Female·aortic dissection (Stanford Type A)

A 71-year-old woman presented to hospital with pericardial effusion causing cardiac tamponade, successfully treated by pericardiocentesis. The underlying cause was a Stanford Type A aortic dissection, which was not ident…

cardiologyradiologydiagnosticcommunicationnoradrenaline
TAShome2017-02-20

Coroner's Finding: Macdonald, Shauna Maree

38y · Female·Pentobarbital toxicity

A 38-year-old woman with advanced Huntington's disease died from pentobarbital toxicity after intentional ingestion. She had progressive neurological decline with awareness of end-stage disease complications. The coroner…

emergency medicineintensive carepentobarbital
VIChospital2017-02-20

Finding into death of Ms A

34y · Female·Global cerebral ischaemia secondary to mixed drug toxicity including a substance…

A 34-year-old woman with a 10-year history of heroin dependence died from mixed drug toxicity including heroin after injecting in a public toilet. She had engaged intermittently with methadone programs and expressed a re…

emergency medicineintensive caresystemheroin
VIChospital2017-02-17

Finding into death of Christopher Albert Nance

67y · Male·ischaemic heart disease

A 67-year-old man with ischaemic heart disease and paroxysmal atrial fibrillation underwent arthrotomy for septic arthritis of the knee. He developed post-operative delirium attributed to anaesthesia, analgesics (tramado…

cardiologyorthopaedic surgerycommunicationproceduraltramadol
QLD2017-02-10

Sloan, Dane Benjamin

24y · Male·Hypoxic ischaemic encephalopathy due to or as a consequence of being hanged

Dane Benjamin Sloan, a 24-year-old remand prisoner with mental health history including suicidal ideation, hanged himself in the Maximum Security Unit exercise yard at Brisbane Correctional Centre. Although CCTV monitore…

psychiatryemergency medicinesystemdelayamitriptyline
NSW2017-02-03

Inquest into the death of Thanh PHAM

30y · Male·traumatic brain injury

Thanh Pham, a 30-year-old karate student, died from traumatic brain injury sustained during a black belt grading when he was repeatedly knocked down and struck to the head while sparring. Critical clinical lessons includ…

neurosurgeryemergency medicinecommunicationsystem
SAhospital2017-02-01

Coroner's Finding: KLINGBERG Briony Caitlin

10y · Female·Multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infecti…

A 10-year-old girl died from multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infection. She presented to the Women's and Children's Hospital on day 3 of pharyngitis with ulceration of the tonsill…

paediatricsemergency medicinediagnosticcommunicationceclor
TAShospital2017-01-03

Coroner's Finding: Summerfeldt; Ian Patrick

48y · Male·sepsis and renal failure due to perforated gastric ulcer

A 48-year-old man with hepatitis C and schizo-affective disorder presented to West Coast District Hospital on 20 October 2014 with severe abdominal pain radiating to the right shoulder tip, generalised tenderness, and a …

emergency medicinegeneral practicediagnosticdelayketorolac
VICmental health2017

Finding into death of Trevor William Brown

49y · Male·Hypoxic brain injury following cardiac arrest due to myocardial infarction with …

Trevor William Brown, a 49-year-old Aboriginal man with chronic schizophrenia, died from hypoxic brain injury following cardiac arrest due to acute myocardial infarction with right coronary artery thrombosis while in psy…

psychiatryemergency medicinedroperidol
VIChospital2017

Finding into death of Nghi Trieu Gla Pham

4y · Male·Complications of T-cell lymphoma

Nghi Pham was a 4-year-old admitted to Sunshine Hospital with facial swelling, stridor, and upper respiratory symptoms. He was examined by emergency and ENT teams, diagnosed with adenoiditis and sinusitis, and discharged…

emergency medicineENT surgerycefalexin
VIChospital2017

Finding into death of Mary Fillipas

75y · Female·Complications of multiple injuries sustained when struck by a car (pedestrian)

Mary Fillipas, 75 years old, died from complications of injuries sustained when struck by a car while crossing Station Street in Burwood on 8 May 2017. She suffered multiple serious injuries including subarachnoid haemor…

trauma surgeryintensive care
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