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TAShospital2024-12-17

Coroner's Finding: Brown, Paul Louis

64y · Male·Subdural haematoma with mass effect following thrombolysis for acute myocardial …

A 64-year-old man with complex medical history including diabetes, mental illness, chronic alcohol misuse, and previous traumatic brain injury was admitted with diabetic ketoacidosis and acute kidney injury. He developed…

intensive carecardiologytenecteplase
VIC2024-12-13

Finding into death of Michael Garry Suckling

41y · Male·Cardiomegaly in a man with WHO Class III obesity

Michael Suckling, a 41-year-old Aboriginal man, died in prison from cardiomegaly secondary to morbid obesity (BMI 54.5). He gained approximately 117kg during his 3-year incarceration, with rapid initial weight gain from …

general practicepsychiatrysystemcommunicationmethadone
NThospital2024-12-06

Inquest into the death of Baby G

0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…

Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…

neonatologypaediatricsdiagnosticsystem
ACThospital2024-12-06

Inquest Into The Death Of Rozalia Spadafora

5y · Female·myocarditis

A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…

emergency medicinepaediatricsdiagnosticcommunication
QLDhome2024-12-06

Inquest into the death of Audrey Yvette Carrick

83y · Female·Pulmonary thromboembolism due to aortic stenosis (recent transcatheter aortic va…

An 83-year-old woman with severe aortic stenosis, atrial fibrillation, and heart failure died from pulmonary embolism one day after discharge following transcatheter aortic valve replacement (TAVI). Clinical lessons cent…

cardiologycardiothoracic surgerycommunicationdocumentationwarfarin
NSWhome2024-11-28

Inquest into the death of Michael Peachey

27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…

Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…

emergency medicinepsychiatryproceduralcommunicationdroperidol
VIChospital2024-11-27

Finding into death of Michael Ruawai Robin

59y · Male·Respiratory failure with paraplegia as a significant contributing factor

Michael Ruawai Robin, a 59-year-old man with paraplegia and incomplete quadriplegia (C4-C6), died from respiratory failure at Werribee Mercy Hospital on 22 June 2023. He presented with a rash and urinary tract infection …

emergency medicinecardiology
QLDcommunity2024-11-18

Inquest into the death of Ashley Charles Washington

31y · Male·Undetermined

Ashley Washington, a 31-year-old Kamilaroi man, died after police restraint and sedation during arrest in Toowoomba. He was apprehended following a report of property theft and stabbed a police dog and officer with sciss…

emergency medicineparamedicinediagnosticcommunicationmethamphetamine
WAhospital2024-11-13

Inquest into the death of Chloe Grace Tupper

31y · Female·organ failure due to anorexia nervosa

Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…

psychiatrypaediatricssystemcommunicationmirtazapine
VIChospital2024-11-13

Finding into death of James Robert Burns

62y · Male·Pulmonary oedema and aspiration in the setting of Down Syndrome and chronic obst…

James Robert Burns, a 62-year-old man with Down syndrome and COPD, died from pulmonary oedema and aspiration at Sunshine Hospital. He was an NDIS participant residing in specialist disability accommodation with support w…

emergency medicinegeneral medicine
VIChospital2024-11-11

Finding into death of Catherine Barker

60y · Female·Tachyarrhythmia and hyperkalaemia leading to sudden cardiac death in the setting…

Catherine Barker, a 60-year-old woman with intellectual disability living in supported accommodation, died from tachyarrhythmia and hyperkalaemia leading to sudden cardiac death in atrial fibrillation. She had been diagn…

cardiologyemergency medicine
QLDhospital2024-11-08

Non-inquest findings into the death of SD

61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed

A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…

haematologypathologydiagnosticcommunicationprednisolone
VIChospital2024-10-28

Finding into death of Julia Mary Case

54y · Female·Pneumonia in the setting of cyanotic congenital heart disease

Julia Mary Case, aged 54, died from pneumonia complicated by cyanotic congenital heart disease. She was admitted to hospital with reduced mobility and shortness of breath, treated with intravenous antibiotics which prove…

general medicinecardiologyantibiotics
TAShospital2024-10-18

Coroner's Finding: Long, Leonard

73y · Male·subdural haematoma from fall

Leonard Athol Long, a 73-year-old on warfarin for mechanical mitral valve replacement, fell twice during hospitalization for urinary tract infection. He was on SMZ-TMP antibiotics, which interact significantly with warfa…

general medicineemergency medicinediagnosticsystemwarfarin
VIC2024-10-16

Finding into death of Craig John Reynolds

62y · Male·Hypertensive and ischaemic heart disease in a man with diabetes mellitus

Craig John Reynolds, 62, died from hypertensive and ischaemic heart disease with diabetes mellitus. He was residing in NDIS-funded short-term accommodation at Carroll House when he suffered a fall on 22 June 2023. He sub…

cardiologygastroenterologyoxycodone
TAShospital2024-10-11

Coroner's Finding: Vieth, Karl Heinz

92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…

A 92-year-old man with complex cardiac history was admitted to Royal Hobart Hospital with chest pain and atrial fibrillation. He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, …

general medicineemergency medicinesystemdelaymelatonin
TAShospital2024-09-30

Coroner's Finding: Newell, Warren James

71y · Male·raised intracranial pressure caused by left frontal-temporal-parietal subdural h…

Warren James Newell, a 71-year-old man with oesophageal cancer, presented with acute coronary syndrome on 29 September 2022 and was appropriately diagnosed and treated with anticoagulation and dual antiplatelet therapy. …

cardiologyemergency medicinemedicationsystemenoxaparin
TAScommunity2024-09-27

Coroner's Finding: Roberts, Leigh Ronald

56y · Male·coronary atherosclerosis

Leigh Ronald Roberts, 56-year-old male, died from coronary atherosclerosis with severe stenosis affecting all three main coronary arteries. He presented to his GP on 17 and 21 February 2020 with respiratory symptoms (cou…

general practicecardiologydiagnosticcommunicationamoxicillin
WAhospital2024-09-24

Inquest into the death of Raymond Sydney CHEEK

89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…

Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarin…

emergency medicineendocrinologymedicationsystemryzodeg insulin
SA2024-09-13

Coroner's Finding: Mortess, Noel Allen

75y · Male·End stage myelodysplastic syndrome and end stage renal failure on a background o…

A 75-year-old man died in prison custody from end-stage myelodysplastic syndrome and renal failure on a background of ischaemic heart disease, hypertension, valvular disease, and metastatic prostate cancer. He was admitt…

general medicinehaematologydelaysystemcefuroxime
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