Coronial
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VIC2022-02-10

Finding into death of Elaine Betty Sime

72y · Female·multi-organ failure secondary to poly-trauma and likely bee-sting related toxidr…

Elaine Betty Sime, a 72-year-old fit and healthy woman, died from multi-organ failure following poly-trauma and bee sting toxidrome after a tree fell on her during a walk. The tree at Ruffey Lake Park Trail failed due to…

emergency medicinetrauma surgerysystem
VIChome2021-12-08

Finding into death of Mark Clinton Edwards

52y · Male·Stab injuries to the chest

Mark Edwards, a 52-year-old man, died by suicide via stab injuries to the chest on 11 December 2020. He had suffered a workplace injury in 2007 resulting in amputation of his right leg in 2017, chronic pain, multiple sur…

general practiceorthopaedic surgerydiagnosticcommunicationamitriptyline
VIChospital2021-12-06

Finding into death of Ingeburg Hildegard Muller

85y · Female·Staphylococcus bacteremia complicating multiple injuries sustained in a motor ve…

An 85-year-old woman sustained multiple serious injuries (bilateral rib and pelvic fractures, thoracic spine fractures) in a motor vehicle collision on 20 June 2018. She was treated with ICU admission, induced coma, and …

emergency medicineintensive caresystemantibiotics
NSWhospital2021-12-02

Inquest into the death of Joshua Szczudlo

33y · Male·Fatal cardiac arrhythmia, secondary to acute kidney injury

Joshua Szczudlo, a 33-year-old man with morbid obesity (estimated weight 195kg), underwent shoulder fracture repair surgery on 17 March 2016 at Liverpool Hospital. He died 38 hours post-operatively from a fatal cardiac a…

orthopaedic surgeryanaesthesiasystemcommunicationmorphine
SAaged care2021-11-25

Coroner's Finding: McCormack, Donald Stewart

81y · Male·pneumonia complicating surgery for left hip fracture on a background of ischaemi…

An 81-year-old man with end-stage dementia, severe frontal lobe injury, and ischaemic heart disease died from pneumonia following hip fracture surgery. He fell while hip protectors were being cleaned after bowel incontin…

geriatric medicineorthopaedic surgery
NSWhospital2021-11-19

Inquest into the death of Emiliana OBUSAN

1y · Female·unrecognised oesophageal intubation

A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of pe…

anaesthesiaorthopaedic surgerydiagnosticcommunicationfentanyl
VIChospital2021-08-11

Finding into death of Mariza Beretta

52y · Female·Presumed SUDEP (Sudden Unexplained Death in Epilepsy)

Mariza Beretta, a 52-year-old woman with Trisomy 21 and early-onset Alzheimer's disease, died from presumed SUDEP (Sudden Unexplained Death in Epilepsy) at Royal Melbourne Hospital. She was diagnosed with genetic general…

neurologygeriatric medicinesodium valproate
TASaged care2021-07-14

Coroner's Finding: Cano, Carmen

84y · Female·complications of a fractured left hip suffered in an unwitnessed fall in aged ca…

An 84-year-old woman with dementia and osteoporosis residing in aged care suffered an unwitnessed fall in a corridor, sustaining a left hip fracture. She underwent high-risk surgical repair on day 3 post-fall. Post-opera…

geriatric medicineorthopaedic surgerydiagnostic
SAhospital2021-06-30

Coroner's Finding: VOIVODICH Guido

84y · Male·general inanition on a background of end-stage dementia and a fractured neck of …

84-year-old man with end-stage dementia died from general inanition following a fractured neck of femur sustained while under a Level 2 Inpatient Treatment Order. He was admitted in January 2019 with confusion and agitat…

psychiatrygeriatric medicineapixaban
TAShospital2021-05-12

Coroner's Finding: Porthouse, David John

70y · Male·uraemic encephalopathy

David John Porthouse, a 70-year-old man with chronic kidney disease, diabetes, and cardiac disease, fell at home in February 2020 causing a neck of femur fracture. He was treated surgically and remained hospitalised. Dur…

orthopaedic surgerygeneral medicine
VIChospital2021-04-14

Finding into death of Mark James O'Brien

56y · Male·Complications of atraumatic bilateral femoral fractures (repaired) during a seiz…

Mark O'Brien, a 56-year-old man with Down syndrome and dementia, sustained multiple seizure-related bilateral femoral fractures. A subtle posterior cortical fracture to his left femur, sustained during a seizure on 15 Ju…

orthopaedic surgerygeriatric medicinediagnosticcommunicationsodium valproate
TAShospital2021-04-12

Coroner's Finding: Fowler, Alice Mary

91y · Female·Pelvic haematoma complicating a fracture of the neck of the left femur

Mrs Fowler, a 91-year-old woman with dementia, poor hearing, and documented high fall risk, was admitted to Royal Hobart Hospital after a home fall. She fell from her hospital bed on 4 December 2015, fracturing her hip a…

geriatric medicineorthopaedic surgerysystemdelay
QLDhospital2021-02-24

Petzler, Dennis Michael

59y · Male·Carcinomatosis due to adenocarcinoma of the pancreas

Dennis Petzler, a 59-year-old prisoner, died from carcinomatosis due to adenocarcinoma of the pancreas with extensive metastatic spread. He presented with abdominal pain and nausea in June 2018, initially managed as gast…

oncologygeneral medicinedexamethasone
VIChome2021

Finding into death of Tate Hobbs

36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)

A 36-year-old motor mechanic with chronic pain from a 2014 knee injury died from combined drug toxicity (pregabalin, morphine, amitriptyline). His general practitioner, Dr S., prescribed excessive amounts of multiple med…

general practicepain medicinemedicationcommunicationpregabalin
NTaged care2020-12-18

Inquest into the death of Barbara Francis

78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…

Barbara Francis, a 78-year-old resident with dementia at Pearl Supported Care in the dementia unit (Dinah), was punched by another resident (Mr A) on 4 September 2018 and fell backward onto her right hip, sustaining an o…

geriatric medicineorthopaedic surgerysystemcommunication
VIChospital2020-11-25

Finding into death of Eoghan Jerome Arnold

42y · Male·Hypoxic ischaemic brain injury secondary to cardiac arrest caused by massive pul…

A 42-year-old man died from hypoxic ischaemic brain injury following cardiac arrest due to a massive pulmonary embolism. He sustained a tibial fracture in a motor vehicle accident and underwent external fixation. He deve…

orthopaedic surgeryanaesthesiasystemenoxaparin
VICaged care2020-11-05

Finding into death of Sylvia Valerie Woolford

88y · Female·Complications of fractured neck of femur

An 88-year-old woman with advanced dementia died from complications following a fractured neck of femur sustained in a fall caused by another resident with vascular dementia in a secured aged care unit. The fall occurred…

geriatric medicineorthopaedic surgerysystem
WAhospital2020-10-19

Inquest into the Death of Renee Desiree RUYZING

21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg

A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…

orthopaedic surgeryemergency medicinediagnosticmedicationenoxaparin
NSWhospital2020-10-02

Inquest into the death of Madeline Newcombe

63y · Female·Pulmonary thromboembolism

A 63-year-old woman died from pulmonary thromboembolism within 24 hours of bilateral total knee arthroplasty despite aspirin and sequential compression devices. The surgeon assessed her as standard risk and did not presc…

orthopaedic surgeryanaesthesiacommunicationdiagnosticaspirin
VIChospital2020-09-28

Finding into death of Graham William Summerfield

82y · Male·Complications of multiple injuries (palliated), sustained in a quad bike inciden…

An 82-year-old man died from complications of multiple injuries sustained in a quad bike incident. He had failed a VicRoads eyesight test two years earlier, losing his driver's licence, yet continued riding an unregister…

trauma surgeryintensive care
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