Coronial
VICcommunity2023-08-28

Finding into death of Jorgen Bottern

86y · Male·carbon monoxide poisoning

An 86-year-old man with recent stroke, declining mental health, and expressed suicidal ideation died by carbon monoxide poisoning. He was assess…

psychiatrygeneral practicesystem
VIChospital2011-07-29

Finding into death of Marlene Kenny

64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…

… (arm weakness, slurred speech) suspicious for TIA. The hospital failed to recognise she had a paradoxical stroke caused by a patent foramen ovale allowing a blood clot to cross from right to left circulation. Transfer t…

emergency medicinegeneral practicediagnosticcommunicationdiazepam
NSWhospital2020-02-25

Inquest into the death of Kerry Curtis

78y · Male·multi-lobar pneumonia and pleural effusions on a background of urothelial carcin…

…after being deemed unsuitable for chemotherapy due to frailty and neutropenia, complicated by an ischaemic stroke. His family requested cessation of active treatment on 30 October, and he died the following morning. The …

oncologygeriatric medicine
NSW2023-02-09

Inquest into the disappearance and suspected death of Alexander Stetz

72y · Male·Unable to be determined

…ander Stetz, a 72-year-old man with significant dementia, hypertension, coronary artery disease, and prior stroke, disappeared on 14 July 2014 from a remote property in Sackville, NSW while under the care of his long-ter…

geriatric medicineemergency medicine
VIChome2015-03-18

Finding into death of Christopher John Dokos

45y · Male·Complications of heat stroke in a man with schizophrenia

Christopher Dokos, a 45-year-old man with schizophrenia on Clozapine treatment, died during the extraordinary January 2014 Victorian heatwave. He had multiple heat-vulnerability risk factors: mental illness, antipsychoti…

psychiatrygeneral practicesystemdelayclozapine
VIChome2017-06-21

Finding into death of Mrs DA

59y · Female·Multiple drug toxicity (propoxyphene, citalopram, oxazepam and others)

…ple drug toxicity (propoxyphene, citalopram, oxazepam and others) in March 2014. She had suffered a severe stroke in 2006 with resultant significant disability, chronic pain, and subsequent depression with suicidal ideat…

rehabilitation medicinegeneral practicepropoxyphene
NSWhospital2025-02-03

Inquest into the death of Stephen Paul Bourke

67y · Male·Liver abscess and complications thereof on the background of pancreatic adenocar…

…eatic adenocarcinoma. He had multiple comorbidities including coronary artery disease, diabetes, and prior stroke. The coroner found he died of natural causes and was appropriately cared for throughout his incarceration.…

palliative careoncologychemotherapy
QLDaged care2024-09-19

Non-inquest findings - a resident

85y · Male·Heat stroke

An 85-year-old man with dementia, diabetes, and aortic stenosis died from heat stroke after spending 2 hours 18 minutes unmonitored in an unsheltered outdoor garden area at a residential aged …

geriatric medicineemergency medicinesystemcommunication
NSWhospital2024-10-29

Inquest into the death of Roger Rogerson

83y · Male·Intracranial haemorrhage

…agnosed—a rare condition causing amyloid protein buildup in cerebral artery walls, leading to haemorrhagic stroke and dementia. He was transferred to the Aged Care Unit and later hospitalised for congestive cardiac failu…

neurologygeriatric medicine
NT2005-10-31

Inquest into the death of Angus Lawrence

25y · Male·acute heat stroke

Trooper Angus Lawrence, a 25-year-old soldier, died from acute heat stroke on 10 November 2004 during a military training exercise at Mount Bundey, NT. He collapsed during a patrol …

paramedicineoccupational and environmental healthdiagnosticcommunication
WA2015-04-17

Inquest into the Death of Danielle Kiesha LANE

8y · Female·heat stroke and dehydration

An 8-year-old girl from Tjirrkarli, a remote Aboriginal community in Western Australia, died from heat stroke and dehydration after becoming stranded in the desert. On 31 December 2011, she and an adult companion bec…

VIChospital2011-07-12

Finding into death of Hugh McKay

Male·Cerebrovascular accident and renal impairment

…terventions, or diagnostic decisions, specific preventability cannot be determined. Standard approaches to stroke recognition, rapid imaging, and renal monitoring would be relevant clinical practice points for review in …

neurologynephrology
VIChome2015-03-18

Finding into death of Katrina Ruth Baron

50y · Female·Complications of heat stroke in a woman with schizophrenia

… 50-year-old woman with long-standing schizophrenia treated with clozapine died from complications of heat stroke during an unprecedented Victorian heatwave. She and her partner were not contacted by mental health servic…

psychiatrygeneral practicesystemcommunicationclozapine
QLDaged care2009-10-01

Streader, Leon

68y · Male·coronary atherosclerosis worsened by heat stroke

…renia, epilepsy, obesity, and coronary artery disease, died from coronary atherosclerosis worsened by heat stroke whilst residing in a level-3 accredited hostel on an extremely hot day (40.9°C). He was taking two medicat…

general practicepsychiatrysystemdelaybenztropine
SAhospital2022-03-29

Coroner's Finding: Foster, Clive Anthony

76y · Male·end-stage renal failure

…dney injury superimposed on chronic disease following gallstone-related illness, complicated by pneumonia, stroke, and cardiac dysfunction. He was assessed and deemed unsuitable for dialysis. The coroner found that adequ…

general medicinenephrology
VICcommunity2017-06-14

Finding into death of Noah Zunde

1y · Male·Heat stroke

Noah Zunde, aged 21 months, died from heat stroke on 19 February 2015 after being inadvertently left in a parked motor vehicle by his mother, Romy, who forg…

TAShospital2015-09-07

Coroner's Finding: Weir, Mary

80y · Female·subdural haematoma due to closed head injury sustained in a fall from bed in hos…

…patient became unresponsive, she was treated with a full dose of anticoagulant (Clexane) based on presumed stroke without first performing a plain CT scan to exclude intracranial bleeding. This violated basic medical pri…

emergency medicinegeneral medicinediagnosticmedicationaspirin
NSW2012-10-04

Inquest into the death of Marcus WILSON

19y · Male·Complications arising from hyperthermia, including total organ failure, rhabdomy…

Marcus Wilson, a 19-year-old roofing insulator, died from hyperthermia-induced organ failure, rhabdomyolysis and coagulopathy after working in a roof space during extreme heat (40°C+) without adequate hydration. He consu…

emergency medicineoccupational and environmental healthsystemcommunication
WAhospital2020-11-20

Inquest into the Death of Trent Nathaniel ROBERTSON

44y · Male·head and neck injuries with terminal palliative care

Trent Robertson, 44, died from severe head and neck injuries sustained in a high-speed motorcycle crash on 27 May 2018 after evading a brief police traffic stop. Police observed him speeding at 92 km/h in a 60 km/h zone,…

trauma surgeryintensive care
SAhospital2011-11-15

Coroner's Finding: TILKA Susan Marie

52y · Female·haemorrhage from a tracheal-innominate artery fistula complicating a tracheostom…

… haemorrhage due to a tracheal-innominate artery fistula 10 days after percutaneous tracheostomy following stroke and decompressive craniectomy. Minor bleeding was observed 3 days before death. The coroner found no short…

neurologyintensive care
145612

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