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SAhospital2024-05-22

Coroner's Finding: Kolega, Sime

54y · Male·multi-organ failure and sepsis complicating fulminant pneumonia with empyema (op…

A 54-year-old man died from sepsis and multi-organ failure secondary to fulminant pneumonia with empyema. He presented to his GP on 1 April 2021 with concerning signs including bilateral oedema, fever, and respiratory sy…

general practiceemergency medicinedelaysystemflixotide
SAaged care2024-05-22

Coroner's Finding: Reid, Betty Lorraine

84y · Female·Alzheimer's disease with subdural haematoma from traumatic head injury as a cont…

Mrs Betty Reid, aged 84 years with advanced Alzheimer's disease, died from Alzheimer's disease with subdural haematoma from traumatic head injury as a contributing factor. She sustained an unwitnessed fall on 1 November …

geriatric medicineneurology
SAhospital2024-05-16

Coroner's Finding: Fisher, Lynne Patricia

60y · Female·sepsis due to community acquired pneumonia

Lynne Patricia Fisher, 60, presented to Mount Barker Hospital ED on 26 September 2018 with bilateral community-acquired pneumonia and was discharged after 6.5 hours despite clinical deterioration. She collapsed at home w…

emergency medicinegeneral practicediagnosticdelayamoxicillin/clavulanate
SAhospital2024-03-27

Coroner's Finding: Collins, Jennifer Ann

30y · Female·tricuspid valve bacterial endocarditis

Jennifer Collins, a 30-year-old intravenous methylamphetamine user, died from tricuspid valve bacterial endocarditis on 6 September 2018. She presented to Noarlunga Hospital ED on 20 August 2018 with chest tightness, fev…

emergency medicinecardiologydiagnosticcommunicationmethamphetamine
SAcommunity2024-01-23

Coroner's Finding: Chua, Ardebby Oh

41y · Female·salt water drowning

Ms Ardebby Chua, a 41-year-old woman with no snorkelling experience, died from salt water drowning during a guided snorkelling tour near Blyth Island, South Australia. She aspirated water triggering laryngospasm and beca…

emergency medicinediving medicinesystemcommunication
SAaged care2024-01-19

Coroner's Finding: Bell, Aileene

85y · Female·general inanition on a background of vascular dementia and a recent right neck o…

An 85-year-old woman with vascular dementia, congestive cardiac failure, and atrial fibrillation sustained a right neck of femur fracture from a fall at her aged care facility on 5 August 2020, despite being on a sensor …

geriatric medicineorthopaedic surgery
SAaged care2024-01-19

Coroner's Finding: Elliott, Ronald Arthur

80y · Male·aspiration pneumonia on a background of severe oropharyngeal dysphagia and chron…

Ronald Arthur Elliott, aged 80, died of aspiration pneumonia complicated by severe oropharyngeal dysphagia and COPD following a hip fracture. He fell on 12 June 2020, underwent left hip hemiarthroplasty at Flinders Medic…

orthopaedic surgerygeneral medicine
SAhospital2024-01-19

Coroner's Finding: Le, Tu Loan

54y · Female·metastatic squamous cell carcinoma of the lung

Tu Loan Le, a 54-year-old woman on home detention release from prison, died from metastatic squamous cell carcinoma of the lung at The Queen Elizabeth Hospital on 9 May 2020. She had been diagnosed with stage 4 lung canc…

oncologypalliative care
SAhospital2023-12-22

Coroner's Finding: FORREST, John Michael

68y · Male·Multi-organ failure due to gram-negative sepsis on a background of recent myocar…

A 68-year-old male prisoner with multiple comorbidities (diabetes, end-stage renal failure, COPD, morbid obesity) presented with acute myocardial infarction and underwent coronary artery bypass grafting. Post-operatively…

cardiothoracic surgerycardiologyglyceryl trinitrate
SAaged care2023-12-22

Coroner's Finding: LENS, Christopher

64y · Male·hypoxic-ischaemic encephalopathy and its complications following cardiac arrest …

Christopher Lens, a 64-year-old man with schizophrenia under guardianship at a nursing home, died from hypoxic-ischaemic encephalopathy following cardiac arrest due to upper airway obstruction after choking on a peanut b…

geriatric medicinespeech pathologysystemcommunication
SA2023-12-22

Coroner's Finding: Schuster, Gavin Shawn

45y · Male·Liver failure due to metastatic hepatocellular carcinoma

A 45-year-old male prisoner died from liver failure due to metastatic hepatocellular carcinoma. He had been prescribed cyproterone (Androcur) for 20+ years as an anti-libidinal agent, with regular blood tests monitoring …

psychiatryoncologycyproterone
SAhome2023-12-06

Coroner's Finding: Cullen, Jason Mark

37y · Male·mixed drug toxicity with fentanyl as the principal agent

37-year-old Jason Cullen died from mixed drug toxicity with fentanyl as the principal agent. He had chronic idiopathic intracranial hypertension requiring multiple neurosurgeries and was prescribed opioids and benzodiaze…

neurosurgerypsychiatrycommunicationsystemfentanyl
SA2023-12-05

Coroner's Finding: Graham, Alan Leslie

79y · Male·undetermined - presumed death following vehicle breakdown while attempting to wa…

Alan Leslie Graham, 79, disappeared from Angepena Station near Leigh Creek, South Australia between 30 April and 2 May 2016. He was an experienced traveller with a keen interest in geology who frequently visited remote p…

pantoprazole
SAprison2023-11-10

Coroner's Finding: Trotta, Giovanni

58y · Male·acute bronchopneumonia

Giovanni Trotta, aged 58, died in custody from acute bronchopneumonia. He was a vulnerable prisoner with COPD, schizoaffective disorder, and profound deafness. Clinical lessons include: (1) hospital discharge summaries m…

emergency medicinerespiratory medicinediagnosticcommunicationclozapine
SAhospital2023-11-09

Coroner's Finding: Jablanovic, Branko

61y · Male·congestive cardiac failure due to cardiomegaly with left ventricular hypertrophy

A 61-year-old man with diabetes, obesity, and high cholesterol presented to his GP with shortness of breath for 4-5 days and tachycardia (HR 120). The GP diagnosed anxiety instead of cardiac failure, failed to ask critic…

general practicecardiologydiagnosticmedicationpropranolol
SAcommunity2023-10-13

Coroner's Finding: Adams, Michael Gerard

62y · Male·cardiac arrest complicating psychotic episode

Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applie…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
SAhospital2023-10-12

Coroner's Finding: Philp, Afrika Rose Pearl

17y · Female·multiple injuries

Afrikah Rose Pearl Philp, aged 17, died from multiple injuries sustained in a high-speed vehicle collision on 6 October 2017 while being pursued by police. She had a complex medical history including psychogenic non-epil…

neurosurgerytrauma surgerysystemmethamphetamine
SAmental health2023-09-20

Coroner's Finding: Chessell, David Edward

43y · Male·compression of the neck due to hanging

A 43-year-old male veteran died by hanging in a psychiatric inpatient unit while under a Level 2 Inpatient Treatment Order. He was admitted after a high-lethality suicide attempt involving overdose and carbon monoxide ex…

psychiatryemergency medicinesystemcommunicationmirtazapine
SAhome2023-09-20

Coroner's Finding: Norman, Colin

66y · Male·unascertained (differential diagnosis: chronic alcoholism with alcohol withdrawa…

Colin Norman, a 66-year-old man with significant disability from traumatic brain injury, chronic alcoholism and liver cirrhosis, died at home after failing to receive essential disability support services over a weekend.…

geriatric medicinesystemcommunication
SAhospital2023-08-30

Coroner's Finding: Fergusson, Logan Scott

0y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease

Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Chil…

cardiologypaediatricsdelaydiagnosticheparin
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