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NSWhospital2016-12-21

Inquest into the death Kyran DAY

0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…

Kyran Day, a 6-month-old boy, presented to Shoalhaven District Memorial Hospital with vomiting and lethargy on 19 October 2013. He was initially assessed and diagnosed with gastroenteritis based on recent rotavirus vacci…

paediatricsemergency medicinediagnosticcommunication
VIChospital2016-12-12

Finding into death of Hugo Edward Byard Gardiner

3y · Male·Streptococcus pyogenes group A pneumonia

Hugo Gardiner, a 3-year-old boy with fever, cough, vomiting and diarrhoea, was assessed twice at Mount Beauty Medical Centre on 23 December 2015 by GPs who diagnosed viral upper respiratory tract infection. Both doctors …

general practicepaediatricsdiagnosticcommunication
VIChospital2016-12-08

Finding into death of David Lay

22y · Male·Multiple stab wounds to chest and abdomen

David Lay, aged 22, died from multiple stab wounds sustained during an altercation at a nightclub in South Yarra on 21 July 2001. He was attacked by unknown assailants while dancing, kicked while on the ground, and stabb…

intensive careemergency medicine
VICmental health2016-12-08

Finding into death of Joseph Pezzimenti

60y · Male·Global cerebral ischaemia post cardiac arrest in the setting of neck compression

Joseph Pezzimenti, a 60-year-old involuntary psychiatric patient, died from cerebral ischaemia following hanging by a tracksuit cord in a Low Dependency Unit bathroom. Key clinical lessons include: communication difficul…

psychiatryintensive carediagnosticcommunication
WAhospital2016-12-02

Inquest into the Death of Jason Barry WINCHESTER

34y · Male·Complications of head injury sustained in motorcycle crash

A 34-year-old man died from complications of severe traumatic brain injury sustained in a motorcycle crash on 11 November 2013, with death occurring 2.5 months later on 29 January 2014. He crashed while evading a police …

trauma surgeryneurosurgerymethamphetamine
NSWhospital2016-11-22

Inquest into the deaths of Sandra BONEY, Norman BONEY and Roger John ADAMS

Organising pneumonia (Sandra Boney and Norman Boney); Organising pneumonia compl…

Three Aboriginal Australians from Walli Reserve (Sandra Boney, 40; Norman Boney, 46; Roger Adams, 37) died within two months in early 2015 following consumption of illegally home-distilled methanol-containing alcohol ('m…

toxicologyemergency medicinediagnosticdelaymethanol
SAmental health2016-11-17

Coroner's Finding: ALCOCK, Ross Matthew

22y · Male·aspiration pneumonia complicating resuscitation for cardiac arrest due to neck c…

A 22-year-old male with acute psychosis was admitted to a mental health ward under a Level 1 treatment order. Despite half-hourly observations, he hung himself using an electrical cord in his wardrobe. The ward layout ha…

psychiatryintensive caresystemcommunicationolanzapine
QLDhospital2016-11-14

Ms H - non-inquest findings

23y · Female·Necrotising retroperitoneal fasciitis due to acute perforated gangrenous appendi…

Ms H, a 23-year-old with Asperger's syndrome and intellectual impairment under OPG guardianship for healthcare decisions, presented to Redcliffe Hospital ED with abdominal pain, vomiting and diarrhoea. Despite clinical c…

emergency medicinesurgerysystemdiagnosticparacetamol
TAShospital2016-11-11

Coroner's Finding: Mr D

21y · Male·Hypoxic encephalopathy complicating cardiac arrest caused by methylamphetamine t…

A 21-year-old man died from hypoxic encephalopathy complicating cardiac arrest caused by methylamphetamine toxicity. He injected the drug at home and collapsed; despite immediate CPR by his uncle and resuscitation at hos…

intensive careemergency medicinemethamphetamine
VIChospital2016-11-10

Finding into death of Beverley Joy Leggett

79y · Female·Pulmonary thromboembolism in the setting of right elective total hip replacement

A 79-year-old woman died from pulmonary embolism eight days after undergoing elective right total hip replacement. She received multimodal VTE prophylaxis including aspirin, early mobilisation, mechanical foot compressio…

orthopaedic surgeryanaesthesiasystemaspirin
QLDhospital2016-11-07

Bower, Malaki Ron - Non-inquest findings

2y · Male·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest secondary to up…

A 2-year-old boy presented to hospital with croup (parainfluenza 1 laryngotracheobronchitis) on 13 July 2013. He was given nebulised adrenaline by ambulance and dexamethasone at hospital, then discharged after only 3 hou…

emergency medicinepaediatricsdiagnosticcommunicationnebulised adrenaline
QLDhospital2016-11-04

Neitsch, Horst - non-inquest findings

77y · Male·Stroke; cardiogenic shock; severe aortic stenosis with three vessel coronary art…

Mr Neitsch, a 77-year-old with severe aortic stenosis, peripheral vascular disease, and reduced left ventricular function, underwent elective coronary angiography at Princess Alexandra Hospital on 21 May 2015. The proced…

cardiologyvascular surgeryproceduralcommunicationfurosemide
NSWhospital2016-11-04

Inquest into the death of Hellen Marsh

50y · Female·Irreversible hypoxic brain injury sustained during surgery for meningioma resect…

Hellen Marsh, a 50-year-old woman with Fragile X Syndrome and a brain meningioma, died from irreversible hypoxic brain injury sustained during tumour resection surgery. Significant intraoperative blood loss (4,500ml esti…

neurosurgeryanaesthesiacommunicationmonitoring
TAShospital2016-10-31

Coroner's Finding: Powell, Arthur John

90y · Male·Sepsis secondary to wound infection/dehiscence and bilateral parotid gland infec…

Arthur John Powell, a 90-year-old with ischaemic heart disease, chronic lung disease, and diabetes, underwent emergency surgical repair of a perforated diverticulum on 1 September 2015. Post-operative recovery was initia…

general surgeryintensive carediagnosticproceduralvenlafaxine
VIC2016-10-28

Finding into death of Peter Edward Hall

71y · Male·Head and neck injury sustained in high-speed motor vehicle collision on racing c…

A 71-year-old experienced motor racing driver suffered fatal head and neck injuries when his Datsun collided with a stalled Lamborghini on the starting grid at Phillip Island Grand Prix Circuit. The driver of the stalled…

emergency medicinetrauma surgerymorphine
NSWhospital2016-10-26

Inquest into the death of Audrey MacGREGOR

88y · Female·combined effects of an overdose of hydromorphone and complications of pneumonia …

An 88-year-old woman with chronic lung disease, heart disease, and recent pneumonia following faecal transplant for clostridium difficile colitis was prescribed 0.5 mg hydromorphone subcutaneously for respiratory distres…

cardiologyrespiratory medicinemedicationcommunicationhydromorphone
WAhospital2016-10-24

Inquest into the Death of David WAYMOUTH

47y · Male·Multi organ failure and sepsis complicating ulcerating colitis and intestinal ob…

David Waymouth, a 47-year-old prisoner with extensive medical comorbidities including hepatitis C, obesity, chronic pain requiring methadone, and depression, fell from his bed in prison and sustained a right hip fracture…

orthopaedic surgerygeneral surgerymethadone
VIChospital2016-10-24

Finding into death of Child A

3y · Male·thrombotic microangiopathy

A 3-year-old child died from thrombotic microangiopathy (haemolytic uraemic syndrome) secondary to Shiga toxin-producing E. coli infection, likely acquired from consumption of unpasteurised milk. Early presentation to GP…

paediatricsemergency medicineondansetron
WA2016-10-18

Inquest into the Death of Giovani Wade RYAN

15y · Male·Severe traumatic brain injury resulting from motor vehicle crash

Giovani Wade Ryan, 15 years old, died from severe traumatic brain injury sustained when the stolen panel van in which he was a front seat passenger rolled at high speed on an unsealed intersection. Young intoxicated male…

emergency medicineintensive carealcohol
NThome2016-10-17

Inquest into the death of Krista Lloyd

36y · Female·myocardial infarction as a consequence of severe focal coronary artery atheroscl…

Krista Lloyd, 36-year-old woman with undiagnosed coronary artery disease presenting with prior chest pain radiating to neck/jaw, suffered sudden out-of-hospital cardiac arrest on 1 May 2015 at home. Initial ECG showed po…

cardiologyemergency medicinediagnosticdelaymorphine
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