Coronial

109 results for type 1 diabetes

VICaged care2013-08-22

Finding into death of MEHMET HASAN

87y · Male·Complications of subdural haematoma and fractured hip following a traumatic inci…

Mr Mehmet Hasan, 87, died from complications of subdural haematoma and fractured hip following an alleged traumatic incident involving staff at Lorikeet Lodge Aged Care on 12 June 2010. Following transfer to hospital, hi…

geriatric medicinegeneral practicesystemcommunication
WApolice custody2017-03-31

Inquest into the Death of Maureen MANDIJARRA

44y · Female·unascertained (consistent with Streptococcus dysgalactiae and Staphylococcus aur…

Maureen Mandijarra, a 44-year-old Aboriginal woman with poorly controlled diabetes and recurrent skin infections, was arrested at Male Oval on 29 November 2012 for street drinking under a …

emergency medicineinfectious diseasesdiagnosticcommunicationalcohol
VIChospital2016-07-14

Finding into death of Ross Albert Butler

67y · Male·Faeculent peritonitis due to perforation of a sigmoid volvulus

Ross Butler, a 67-year-old with dementia and Parkinson's disease, presented with abdominal pain and decreased appetite. A sigmoid volvulus was identified and a rectal tube successfully inserted for decompression. Conserv…

general surgeryemergency medicinecommunicationdocumentationmorphine
NSWhospital2025-02-28

Inquest into the death of Heather Winchester

75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…

A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…

gynaecologyanaesthesiacommunicationsystem
SAhospital2018-03-29

Coroner's Finding: BUTSON Graham Joseph

81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…

Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass w…

orthopaedic surgerygeneral medicinesystemwarfarin
VIChospital2019-01-24

Finding into death of Bryan Lindsay Cleeman

86y · Male·Complications post laparoscopic cholecystectomy

86-year-old man with acute gangrenous perforated cholecystitis underwent laparoscopic cholecystectomy on 2 October 2015, forty-two hours after admission. Severe bleeding from hepatic arterial branches required conversion…

general surgeryanaesthesiadelayasasantin
WAhospital2020-04-24

Inquest into the Death of Hassan BECHARA

52y · Male·ischaemic heart disease

Hassan Bechara, a 52-year-old prisoner, died from ischaemic heart disease in July 2017. He had complex cardiac history including dilated cardiomyopathy, triple-vessel coronary disease, and previous cardiac procedures. Cl…

cardiologyemergency medicinedelaysystematorvastatin
VIChospital2025-02-26

Finding into death of CFT

78y · Female·Bronchopneumonia

CFT, a 78-year-old woman with chronic schizophrenia, intellectual disability, and dementia, died of bronchopneumonia with hypothermia and coronary atherosclerosis. She lived with her nephew RDS who was her carer. Multipl…

geriatric medicinegeneral practicediagnosticsystem
VIChospital2015-12-02

Finding into death of Khodr El Mustapha

77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…

A 77-year-old man with iron deficiency anaemia and underlying ischaemic heart disease died from anaphylaxis following iron polymaltose infusion. Critical clinical lessons: (1) IV iron should only be administered after or…

emergency medicinehaematologydiagnosticproceduraliron polymaltose
VIChome2015-02-20

Finding into death of Phillip George Black

29y · Male·Combined methadone, diazepam and clonazepam toxicity in a man commencing a metha…

Phillip Black, age 29, died from combined methadone, diazepam and clonazepam toxicity after commencing methadone maintenance therapy. He presented to Dr D. on 23 September 2010 seeking to re-commence MMT, having previous…

addiction medicinegeneral practicediagnosticmedicationmethadone
TAShospital2019-02-22

Coroner's Finding: Mansfield, Doreen

78y · Female·Complications arising from a left femur fracture following an unwitnessed fall i…

Doreen Mansfield, a 78-year-old woman with bipolar affective disorder managed with lithium and ECT, was admitted to the Royal Hobart Hospital under a Mental Health Act treatment order. She sustained an unwitnessed fall i…

psychiatryorthopaedic surgerysystemlithium
VIChome2021-12-21

Finding into death of Geoffrey Alan Locks

50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…

A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleedin…

ENT surgeryoncologysystemcommunicationmethadone
NSWcommunity2023-08-01

Inquest into the death of Peter Gretton

64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…

Peter Gretton, a 64-year-old man imprisoned at Junee Correctional Centre, died from metformin toxicity complicated by acute renal impairment and severe lactic acidosis. His renal function deteriorated in the three to fou…

emergency medicinecardiologydiagnosticcommunicationmetformin
NTmental health2025-02-14

Inquest into the death of Pukumani

47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…

Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…

psychiatryemergency medicinediagnosticcommunicationketamine
SA2006-04-28

Coroner's Finding: WALKER Darryl Kym

31y · Male·hanging (self-inflicted)

Darryl Walker, a 31-year-old Aboriginal man with chronic schizophrenia and diabetes, died by hanging in Port Lincoln Prison on 2 June 2003. He had been transferred to an isolated management…

psychiatrygeneral practicediagnosticcommunicationchlorpromazine
VICaged care2013-02-13

Finding into death of Peter Kosciuk

83y · Male·Aspiration pneumonia

An 83-year-old man with stroke, dementia, dysphagia, and multiple comorbidities developed aspiration pneumonia while in aged care. On 1 May 2008, he presented with acute swallowing difficulty and was examined by his GP w…

general practicegeriatric medicinediagnosticcommunicationpenicillin
NSWaged care2016-10-20

Inquest into the death of Savvas Epsimos

84y · Male·Complications of large right subdural haematoma

An elderly man with cognitive impairment and multiple comorbidities fell out of bed at an aged care facility while an assistant in nursing (AIN) was absent obtaining equipment. The AIN had raised the bed to facilitate us…

geriatric medicineemergency medicineproceduralcommunication
VIChospital2012-01-31

Finding into death of Judith Elizabeth Heath

68y · Female·Massive blood loss due to disconnection of haemodialysis machine

Judith Heath, age 68, died from acute blood loss on 7 September 2006 at The Alfred Hospital during routine haemodialysis for end-stage renal failure. The Luer-Lok connection between her arteriovenous catheter and the hae…

nephrologyproceduralsystemheparin
VIChome2015-11-16

Finding into death of Leanne Margaret Patterson

52y · Female·gunshot wound to head

Leanne Patterson, 52, was shot and killed by her husband Neil in a murder-suicide on 5-6 January 2013. She had been sedated with clonazepam (prescribed to her husband) and zolpidem at the time of her death. The death occ…

general practicepain medicinecommunicationsystemclonazepam
NThospital2025-03-25

Inquest into the death of Judith Smart

66y · Female·Hypoxic-ischaemic encephalopathy

A 66-year-old woman with COPD, obstructive sleep apnoea, and obesity underwent routine knee surgery at Royal Darwin Hospital. Post-operative care was inadequate. Despite dropping oxygen saturations to 88% when sedated an…

anaesthesiaorthopaedic surgerydiagnosticsystemmorphine

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