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TASaged care2022-11-09

Coroner's Finding: Tate, Barry Ronald

75y · Male·bronchopneumonia

Barry Ronald Tate, 75, died of bronchopneumonia following a fall at a palliative care ward. He sustained an unwitnessed fall on 26 September 2019 while attempting to shave himself without assistance, despite being advise…

palliative careoncology
TASaged care2022-11-08

Coroner's Finding: Kerr,Anthony Neville

81y · Male·pneumonia due to traumatic internal bleeding of the chest wall sustained in fall…

An 81-year-old man with Parkinson's disease, dementia, and multiple comorbidities residing in aged care suffered an unwitnessed fall on 6 June 2021, sustaining a right-sided chest wall haematoma. Staff found him at 7:40a…

geriatric medicineemergency medicinedelaysystem
VIChospital2022-11-03

Finding into death of Sotirios Temopoulos

76y · Male·Chest sepsis in a man with ischaemic heart disease

A 76-year-old man with multiple myeloma and complex medical history died from chest sepsis and myocardial infarction following a medication dispensing error. After discharge from hospital for spinal compression fractures…

pharmacyhaematologymedicationsystemvalsartan
WAhospital2022-11-03

Inquest into the Death of Jeffery William ROONEY

41y · Male·subarachnoid haemorrhage due to rupture of a berry aneurysm of the right interna…

A 41-year-old male prisoner died from subarachnoid haemorrhage caused by rupture of an undiagnosed berry aneurysm while incarcerated. He had a complex medical history including migraines, head injuries, hypertension, and…

neurosurgeryemergency medicineamitriptyline
TAShome2022-10-31

Coroner's Finding: Lampkin, Christopher Maxwell

57y · Male·hanging

Christopher Maxwell Lampkin, a 57-year-old man with longstanding depression and alcohol dependence, died by hanging in July 2021. He had been treated for depression since 2009 and had attended an alcohol and drugs servic…

general practicepsychiatryantidepressant
VIChome2022-10-31

Finding into death of Master S

13y · Male·Asthma

Master S was a 13-year-old Aboriginal boy with severe persistent asthma who died at home on 13 November 2019. He was found unresponsive with his nebuliser mask on his face. The coroner accepted that death resulted from a…

respiratory medicineallergy and immunologysystemfluticasone/vilanterol
NSWhospital2022-10-28

Inquest into death of Dane LOCKWOOD

33y · Male·methylamphetamine toxicity; antecedent causes being the physiological effects of…

A 33-year-old man with methamphetamine addiction and possible schizophrenia attended the ED seeking help while acutely intoxicated, psychotic and sleep-deprived. After initially agreeing to medication, he attempted to le…

emergency medicinepsychiatrysystemdelaymethamphetamine
NSW2022-10-28

Inquest into the death of Todd McKenzie

Male·Consequences of police tactical operation involving use of lethal force (specifi…

Todd McKenzie died following a police operation in Taree involving negotiation attempts, deployment of non-lethal options, and ultimately lethal force. This extensive coronial ruling concerns protective orders over polic…

emergency medicinecorrectional healthsystem
TAShospital2022-10-26

Coroner's Finding: Carroll, Terence John

71y · Male·sepsis caused by mediastinal empyema (abscess) which complicated perforation of …

Terence Carroll, 71, died from sepsis and mediastinal empyema following oesophageal perforation during rigid oesophagoscopy for stricture dilation. Critical failures included: CT scan showing suspicious oesophageal thick…

ENT surgerygeneral surgerycommunicationdiagnostic
NSWhospital2022-10-26

Inquest into death of Lucas PEYRET

21y · Male·Hypoxic brain injury arising from severe anaphylactic shock due to administratio…

Lucas Peyret, a 21-year-old with no significant medical history, presented to hospital with acute appendicitis and underwent emergency laparoscopic appendicectomy. Surgery was routine and uneventful. Upon emergence from …

surgeryanaesthesiasugammadex
TAShome2022-10-25

Coroner's Finding: Meyer, Glenn Sturley

45y · Male·mixed drug toxicity

Glenn Sturley Meyer, aged 45, died from mixed drug toxicity on 22 August 2019. He had chronic pain, PTSD, depression and anxiety managed with oxycodone and diazepam. He also had obesity and probable obstructive sleep apn…

general practicepsychiatryoxycodone
VIChospital2022-10-18

Finding into death of Heather Jean Lucas

80y · Female·Anaphylaxis complicating chemotherapy for the treatment of metastatic fallopian …

Ms Heather Jean Lucas, 80-year-old woman with metastatic fallopian tube cancer, died from anaphylaxis during her third carboplatin chemotherapy infusion. She had experienced a documented Grade 2 hypersensitivity reaction…

oncologyemergency medicinemedicationcommunicationcarboplatin
VICaged care2022-10-14

Finding into death of Beryl Eileen Brindley

74y · Female·Diabetic ketoacidosis

A 74-year-old woman with Type 1 diabetes died from diabetic ketoacidosis (DKA) in an aged care facility. Between 7-10 December 2016, her blood glucose levels remained persistently elevated (>33 mmol/L) despite escalating…

general practiceendocrinologydiagnosticcommunicationinsulin
NSWhospital2022-10-14

Inquest into the death of Malouvailoa Tafau

20y · Male·cardiac arrest due to complications of infective endocarditis against a backgrou…

Maluovailoa Tafau, a 20-year-old man in custody, died from cardiac arrest due to infective endocarditis complicated by rheumatic heart disease. He had submitted two patient self-referral forms (September 2016 and Februar…

cardiologyinfectious diseasesdiagnosticcommunicationflucloxacillin
TASaged care2022-10-13

Coroner's Finding: Krushka, Robert

66y · Male·sepsis following bacteraemia caused by transurethral catheter insertion

A 66-year-old man with severe dementia and multiple comorbidities died from sepsis following bacteraemia after a routine indwelling urinary catheter change at a nursing home. The catheter insertion was traumatic, resulti…

geriatric medicineemergency medicineproceduralsystem
NSWcommunity2022-10-13

Inquest into the death of Harvey McGlinn

0y · Male·positional asphyxia

Harvey McGlinn, a 3-week-old infant, died from positional asphyxia while being carried in a Boba Wrap fabric sling in an incorrect position on 8 April 2019. The sling was positioned horizontally and low across his mother…

paediatricsneonatologysystemparacetamol
VIChospital2022-10-07

Finding into death of Mr B

57y · Male·Subarachnoid Haemorrhage Secondary to Ruptured Pericallosal Aneurysm

A 57-year-old man on remand at Port Phillip Prison collapsed on 4 August 2021 with a subarachnoid haemorrhage from a ruptured pericallosal aneurysm. He was transferred to St Vincent's Hospital, underwent emergency neuros…

neurosurgeryintensive care
WAhospital2022-10-07

Inquest into the Death of Justine PAINTER

51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…

Justine Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient at Royal Perth Hospital (RPH). She had severe treatment-resistant schizoaffective disorder, command h…

gastroenterologypsychiatrycommunicationsystempaliperidone
NSW2022-10-06

Inquest into the death of ZA

Male·Fentanyl toxicity, with aspiration pneumonia as a significant contributing condi…

A man (ZA) died from fentanyl toxicity in custody at Shortland Correctional Centre after his cellmate, who had brought fentanyl into the prison by concealing it in his rectum, shared it with him. Both men snorted the pow…

forensic medicineemergency medicinesystemdelayfentanyl
VIChome2022-10-05

Finding into death of Fiona Lebner

57y · Female·Combined features of moderately stenosed right coronary ostium, aortic valve reg…

Fiona Lebner, a 57-year-old woman with severe intellectual disability living in a group home, died suddenly from acute cardiac arrhythmia secondary to multiple heart abnormalities including aortic valve disease, mitral v…

cardiologyvascular surgerysodium valproate

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