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SAhospital2022-04-13

Coroner's Finding: Cook, Courtney Liza

20y · Female·multi-organ failure due to polypharmacy overdose

A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where i…

emergency medicinegastroenterologydiagnosticcommunicationparacetamol
QLDhospital2016-09-15

Mr B, a 41 year old indigenous man - Non-inquest findings

41y · Male·Subdural haematoma

A 41-year-old Aboriginal man with excessive alcohol use presented four times to a rural hospital over one month with headaches. His symptoms were attributed to cluster migraine, then alcohol withdrawal syndrome, despite …

emergency medicineneurologydiagnosticcommunicationdiazepam
WA2023-09-14

Inquest into the Death of Shane Reynold NARRIER

40y · Male·coronary artery atherosclerosis

…wledge he had reported chest pain. Shane collapsed suddenly nine days later and died despite appropriate emergency treatment. A cardiologist testified that with prompt ECG and hospital referral after 27 May, Shane would…

cardiologyemergency medicinediagnosticcommunicationescitalopram
WAmental health2022-02-25

Inquest into the Death of Jordan James WILLIAMS

20y · Male·head and neck injuries sustained when struck by train

Jordan James Williams, 20, died after being struck by a train following two absconsions from Kalgoorlie Health Campus mental health unit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Crit…

psychiatryemergency medicinesupervisioncommunicationolanzapine
QLDhospital2016-08-19

Plumb, Mark Anthony

76y · Male·Multiple organ failure due to sepsis with peritonitis and pancreatitis, secondar…

A 76-year-old man died from multiple organ failure following an ERCP procedure for gallstone removal. The procedure itself was appropriate and uneventful. Post-operatively, he developed severe abdominal pain and a CT sca…

surgeryanaesthesiadiagnosticcommunicationmorphine
QLDcommunityPodcast2020-06-26

Nyholt, Nicole Sonia and Clark, Margaret Louisa

Female·Burns due to gas explosion due to motor vehicle collision with building

A 60-year-old man with a long-standing history of seizures experienced an epileptic seizure while driving and lost control of his vehicle. It collided with an LPG gas cylinder outside a café, triggering an explosion that…

emergency medicineneurologycommunicationsystem
QLDmental health2026-01-29

Inquest into the death of Tiesha Marie Derbyshire

18y · Female·Mixed drug toxicity

… intentionally overdosing on propranolol while admitted to an acute mental health unit under involuntary treatment. She had a documented history of medication stockpiling and multiple overdose attempts. Key clinical les…

psychiatrygeneral practicecommunicationsystempropranolol
NSWcommunity2021-12-21

Inquest into the deaths of Lars FALKHOLT, Vivian FALKHOLT, Jessica FALKHOLT and Annabelle FALKHOLT, and Craig WHITALL

Male·Combined effects of multiple blunt force injuries and the effects of fire (Craig…

…m his primary prescriber. Key failures: (1) no integrated medication monitoring between prescribers; (2) emergency doctors unaware of Whitall's repeated hospital visits and drug-seeking pattern; (3) decision to supply 2…

general practiceemergency medicinemedicationcommunicationmethadone
SAhospital2017-04-07

Coroner's Finding: MAYELL Edward John

83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…

An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…

emergency medicinegeneral practicediagnosticmedicationceftriaxone
VIChospital2018-06-14

Finding into death of Ian John Gilbert

77y · Male·Complications of methotrexate toxicity in a man with chronic renal impairment, c…

A 77-year-old man with chronic kidney disease, COPD, and mild cardiac failure died from methotrexate toxicity after a GP prescribed it at an inappropriate daily dose (5mg daily) for psoriasis without baseline blood tests…

general practicepharmacydiagnosticmedicationmethotrexate
NSWcommunity2008-01-24

Coroner's Finding: Vanessa Ann Anderson

16y · Female·Respiratory arrest due to the depressant effect of opiate medication

Vanessa Anderson, 16, suffered a depressed skull fracture from a golf ball strike and was admitted to Royal North Shore Hospital. She died from respiratory arrest due to opioid-induced respiratory depression, which was e…

neurosurgeryanaesthesiamedicationcommunicationoxycodone
VIC2024-05-14

Finding into death of Brian Richard Pope

40y · Male·compression of the neck due to hanging

…ks were discontinued after initial assessments despite recent suicidal history and ongoing mental health treatment. The coroner found no adverse comment appropriate but identified system failures in information gatherin…

psychiatrycorrectional healthcommunicationsystemmirtazapine
TAShospital2023-05-05

Coroner's Finding: Pedler, Anne Helen

71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis

71-year-old woman presented to ED with signs of circulatory failure (hypotension, tachycardia, tachypnoea, hypoxia) and progressive leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pulmonary emb…

emergency medicinecardiologydiagnosticdelaycannabis oil
QLDmental health2004-09-30

Cif Lee Ja 20040930

23y · Male·compression of the neck, secondary to coronary arteriosclerosis

Julian Arasina Lee, a 23-year-old man, died on 1 February 2003 during a restraint incident in the Mental Health Unit at Cairns Base Hospital. Admitted voluntarily after exhibiting marked behavioral changes, he became inc…

psychiatryemergency medicineproceduralcommunicationdroperidol
QLDhome2019-11-06

Follent, Mitchell James - Non-inquest findings

22y · Male·Multiple injuries from fall from height

Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired b…

psychiatryneurologydiagnosticcommunicationolanzapine
QLDhospital2011-09-20

Anderson, John Clive

36y · Male·infective endocarditis

…appointment). The patient deteriorated rapidly in late May with pneumonia and cardiac failure, requiring emergency hospital transfer on 30 May where endocarditis was confirmed. Despite aortic valve replacement surgery a…

general practicecardiologydelaycommunicationamoxicillin
NThospital2018-09-21

Inquest into the death of Henry George Wilson aka Albert Wilson

77y · Male·sepsis due to retroperitoneal collection after biliary stent insertion on a back…

…iography (PTC) procedure that perforated his duodenum. Critical failures included: delayed diagnosis and treatment of peritonitis (diagnosis made at 1.20pm on 18 September, appropriate management delayed until late afte…

general surgeryradiologydiagnosticcommunicationpiperacillin/tazobactam
VIChome2026-04-17

Finding into death of Simon Christopher Gaskill

50y · Male·unascertained

…il 2022 after sleeping rough for months. He had been discharged from hospital in December 2021 following treatment for severe alcohol withdrawal and seizures, sent to homelessness without adequate follow-up care. His ca…

emergency medicinegeneral medicinecommunicationsystemalcohol
QLDhospital2011-06-24

(C) a 15 month old child

1y · Male·Complication of burns and trauma to the mesenteric artery

A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unk…

paediatricsplastic and reconstructive surgerycommunicationsystemrisperidone
QLDhospital2017-04-04

Coolwell, Bradley Karl

39y · Male·respiratory failure and cardiac arrest

Bradley Karl Coolwell, a 39-year-old Indigenous Australian with schizo-affective disorder and significant comorbidities (obesity, respiratory infection, diabetes), presented to Logan Hospital after police noted concernin…

emergency medicinepsychiatrydiagnosticcommunicationmidazolam
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