Coronial

103 results for early dementia

QLDaged care2019-06-17

Ms SME - Non-inquest findings

86y · Female·subdural haemorrhage due to or as a consequence of a fall

…tions, CP22 training) address the root cause of staff not following trained procedures despite competency. Early recognition of the subdural haemorrhage on CT and conservative management given age/comorbidities were app…

geriatric medicineemergency medicineproceduralsystemoxycodone
VIChospital2022-01-28

Finding into death of Margaret Rose Ryan

62y · Female·Complications of progressive motor neurone disease

…ed unsuitable for feeding tubes (PEG/NGT). A palliative care pathway was initiated from September 2018. By early October, her condition deteriorated further with reduced jaw tone and food pooling. She was admitted to pa…

palliative careneurologysodium valproate
NSWPodcast2020-12-18

GORE Bernard - Findings

Male·The available evidence does not allow for any finding to be made as to the cause…

Bernard Gore, a man with Alzheimer's dementia, entered a fire stairwell at Westfield Bondi Junction shopping center in Sydney on 6 January 2017 and bec…

systemcommunication
WAcommunity2020-05-26

Inquest into the Suspected Death of Yilmbut UMBUL

73y · Female·Open finding - either natural death from medical conditions (hypertension, angin…

…ilmbut Umbul, a 73-year-old Aboriginal woman living at Walmbie Camp near Kalumburu Mission, disappeared in early March 1982. She was frail, with a history of hypertension, angina requiring daily medication, and document…

WAhospital2019-05-31

Inquest into the Death of Aurelio Monterlegre CRUZ

80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…

…omplicating terminal palliative care while a sentenced prisoner. He had consistently refused dialysis from early 2016 onwards, a decision ultimately supported by his family and considered reasonable by his nephrologist,…

nephrologypalliative carecommunicationdelayinsulin
NSWaged care2019-12-06

Inquest into the disappearance and suspected death of Raymond Speechley

77y · Male·Hypothermia

Raymond Speechley, aged 77 with dementia, absconded from an aged care secure unit on 7 July 2016 and died from hypothermia in bushland. Critical s…

geriatric medicineemergency medicinecommunicationsystemrisperidone
SAhospital2020-05-21

Coroner's Finding: SNIECIKOWSKA Alicja

68y · Female·chronic obstructive pulmonary disease

…anaging non-compliant patients with language barriers, cognitive impairment from hypoxia, and the need for early palliative planning when invasive interventions are refused and prognosis is poor.

respiratory medicineemergency medicinemorphine
VIChospital2024-04-11

Finding into death of Mark Andrew Spillane

58y · Male·Septic shock secondary to intra-abdominal collections as sequelae of osteomyelit…

A 58-year-old man with Down syndrome and multiple comorbidities died from septic shock secondary to intra-abdominal collections caused by osteomyelitis/discitis of the spine. He initially presented with a foot bone infec…

infectious diseasesgeneral medicine
TASmental health2019-06-28

Coroner's Finding: Hughes, Joan May

85y · Female·aspiration of gastric contents following vomiting

…one advice was obtained on 15 June; staff were instructed to monitor vital signs and provide clear fluids. Early on 16 June, she vomited blood-like material and was transferred to hospital but was unrevivable. The coron…

psychiatrygeriatric medicinecitalopram
VICaged care2023-06-27

Finding into death of Elizabeth Ethel Watson

89y · Female·Complications of fractured neck of femur in the setting of a fall in a woman wit…

An 89-year-old woman with dementia and high falls risk sustained a fall at an aged care facility on 24 August 2019. The enrolled nurse in ch…

geriatric medicineemergency medicinediagnosticcommunicationtramadol
WAhospital2021-03-08

Inquest into the Death of Stephen Craig SOLLY

63y · Male·respiratory failure in a man with lung cancer, chronic obstructive pulmonary dis…

Stephen Craig Solly, aged 63, died from respiratory failure due to advanced lung cancer, COPD, and pulmonary fibrosis while an involuntary psychiatric patient at Graylands Hospital. He had paranoid schizophrenia, cogniti…

psychiatryrespiratory medicineduloxetine
VIChospital2010-05-31

Finding into death of Paul Alexander Goodwin

85y · Male·Ruptured abdominal aortic aneurysm

…topsy confirmed death from natural causes (ruptured AAA). Dr T. was commended as a meticulous practitioner early in his internship. The case highlights importance of careful medication verification at admission and syst…

general medicinerespiratory medicinemedicationgabapentin
NSWhospital2019-12-13

Inquest into the death of Lorraine BARNES

85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…

…tional supplements were inadvertently delivered into the lung, causing perforations. Clinical lessons: (1) Early multidisciplinary case conferences should have been convened; (2) Dietician involvement should have been s…

general medicinerespiratory medicinediagnosticsystemciprofloxacin
SAaged care2020-07-09

Coroner's Finding: HANSLOW Walter Robert

75y · Male·bilateral subdural haematoma due to fall

…nd hospital was appropriate and lawful. Clinical lessons include the importance of careful observation and early recognition of deterioration post-fall in elderly patients on anticoagulation or with bleeding risk, and t…

geriatric medicineemergency medicinedelay
SAhospital2018-09-07

Coroner's Finding: MCBRIDE Peter James

86y · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer

…ine, risperidone) worsened delirium and immobility. An erroneous bed-rest policy after admission prevented early mobilisation. When sepsis developed, transfer to specialist care was delayed. The coroner found this death…

general practicegeriatric medicinediagnosticproceduralolanzapine
QLDhospital2018-08-20

RD - Non-inquest findings

64y · Male·Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia…

…tropes, and ICU review at the first hospital could have changed the outcome. Key lessons: recognize sepsis early despite diagnostic uncertainty, act on objective vital sign trends, escalate to senior staff when patients…

emergency medicineintensive carediagnosticmedicationintravenous normal saline
VICmental health2015-09-24

Finding into death of Elaine Elizabeth Sykes

58y · Female·Multiple injuries sustained in collision with train (pedestrian)

Elaine Sykes, aged 58, was admitted to Dandenong Hospital with acute renal failure and severe mental health deterioration. After 47 days at Acacia Mental Health Unit, she demonstrated substantial improvement and was disc…

psychiatrygeneral medicinesystemcommunication
TAShospital2018-05-30

Coroner's Finding: Forward, Trudi Maree

53y · Female·sepsis and multiple organ failure attributable to infarction/necrosis of small b…

A 53-year-old woman with Type II diabetes, obesity, and Korsakoff dementia presented with acute severe abdominal pain from superior mesenteric artery (SMA) thrombosis at 3:00 AM on…

emergency medicinegeneral surgerydiagnosticdelay
VICaged care2020-07-06

Finding into death of Irene Florence Curran

79y · Female·Ischaemic bowel in the setting of cardiomegaly, pneumonia and chronic renal fail…

…While systemic failures in communication were identified, the coroner found they were not causal to death. Early warning signs of bowel ischaemia (abdominal pain, elevated inflammatory markers, wound infection with MRSA…

gynaecologygeneral practicecommunicationsystemoxycodone
WAhome2013

Inquest into the Death of Roll, Robert

75y · Male·Unascertainable due to advanced decomposition; likely lung cancer

…pice arranged home visits, he refused assistance after becoming paranoid, possibly from alcohol effects or early dementia. Silver Chain notified the hospital they were withdrawing care, but Royal Perth Hospital did not …

palliative caregeriatric medicinecommunicationsystem

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