Coronial
WAhospice2021-01-15

Inquest into the Death of Stuart William DUGAN

70y · Male·carcinoma of the lung

…nced lung cancer, died in hospice care. He had multiple missed opportunities for earlier diagnosis. While smoking-related lung cancer commonly presents late with poor prognosis, regular annual health checks were not con…

general practicerespiratory medicinediagnosticcommunicationtramadol
QLD2010-05-19

Jeffrey, Lawrence Edward

63y · Male·Metastatic carcinoma of the lung

Lawrence Jeffrey, a 63-year-old inmate at Lotus Glen Correctional Centre, died from metastatic lung carcinoma on 11 May 2008. He presented with symptoms consistent with his known chronic conditions (asthma, COPD, silicos…

general practicerespiratory medicinediagnosticdelayfurosemide
WA2021-12-21

Inquest into the Death of James Alexander TILBURY

77y · Male·early pneumonia in an elderly man receiving terminal palliative medical care for…

…ound his medical care was excellent overall, with conditions generally well-managed despite his continued smoking. A medication communication error occurred between prison medical staff and the palliative care team rega…

palliative careneurosurgerycommunicationsystemdexamethasone
SAmental health2000-11-14

Coroner's Finding: SIMMONETTE Sean Patrick

26y · Male·respiratory arrest complicating hydrocarbon inhalation (sudden sniffing death)

…lysubstance abuse died from sudden sniffing death syndrome after inhaling fly spray in a psychiatric ward smoking room. Three days prior, staff were alerted to inhalant abuse but failed to adequately respond: no patient…

psychiatryforensic medicinecommunicationsystemchlorpromazine
WAhospital2018-10-12

Inquest into the Death of Augustinus Clemens Antonius HEESTERS

70y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis

A 70-year-old sentenced prisoner with severe ischaemic heart disease and prior myocardial infarctions died from acute myocardial infarction with coronary artery atherosclerosis. He presented with severe chest pain on 5 O…

cardiologyemergency medicinesystemaspirin
VIChome2020-04-17

Finding into death of Karen Frazer

56y · Female·Cardiomegaly

Karen Frazer, a 56-year-old woman with intellectual disability, schizophrenia, anxiety, hypertension, and COPD, died from cardiomegaly (enlarged heart with biventricular hypertrophy). She was found unresponsive on the to…

forensic medicinegeneral practicecarbamazepine
QLDhospital2007-09-27

Effer, Anthony John

27y · Male·exsanguination due to ruptured right kidney, renal vessels, and liver from motor…

Anthony John Effer, aged 27, died from exsanguination following a high-speed motorcycle crash on 26 July 2004. He was a pillion passenger on a motorcycle that left the road at speed and struck a concrete culvert, causing…

emergency medicinetrauma surgeryalcohol
WAmental health

Inquest into the Death of David GRIEVE

45y · Male·Coronary Atherosclerosis

…ar-old man with chronic schizophrenia and multiple cardiac risk factors (hypertension, diabetes, obesity, smoking), died of coronary atherosclerosis while an involuntary psychiatric patient at Graylands Hospital. He pre…

psychiatrycardiologysystemcommunicationhaloperidol
ACThospital2018-01-30

AN INQUEST INTO THE DEATH OF ROBERT DOUGLAS

67y · Male·respiratory failure with antecedent causes including chronic emphysematic lung d…

67-year-old male with 40-year smoking history presented with chest symptoms in 2012. CT scan revealed a left upper lobe mass. Core biopsy was i…

respiratory medicinepathologydiagnosticsystemenoxaparin
SAmental health2000-06-16

Coroner's Finding: FERN Edmund James

30y · Male·cardiac arrhythmia due to therapeutic clozapine use

…triptyline) created cumulative sedative and cardiac effects; clozapine levels were elevated due to recent smoking cessation; no regular medication review or reduction despite multiple overlapping drug effects; inadequat…

psychiatryENT surgerymedicationsystemclozapine
VIC2018-10-26

Finding into death of John Gorman Maltman

71y · Male·Coronary artery atherosclerosis

John Maltman, a 71-year-old man with intellectual disability and early Alzheimer's, died from coronary artery atherosclerosis after leaving residential care on 26 December 2017. He was reported missing after 24 hours and…

VIChospital2016

Finding into death of Barry Foster

79y · Male·Acute myocardial infarction

Barry Foster, a 79-year-old man imprisoned at Hopkins Correctional Centre, died from acute myocardial infarction. On 29 April 2016, he presented with chest tightness; an ECG showed no abnormalities and he was prescribed …

cardiologyemergency medicine
SAhospital2017-11-17

Coroner's Finding: CAMERON George William

76y · Male·pneumonia and exacerbation of chronic obstructive airway disease

George William Cameron, aged 76, died from pneumonia and exacerbation of chronic obstructive airway disease at Noarlunga Hospital. He was admitted with acute alcohol withdrawal, confusion, and respiratory symptoms. A Lev…

psychiatrygeneral medicinesalbutamol
QLD2007-02-23

James, Joseph Edwin

67y · Male·Coronary atherosclerosis and emphysema

Joseph Edwin James, aged 67, died of sudden cardiac arrest due to coronary atherosclerosis and emphysema while imprisoned at Lotus Glen Correctional Centre. He had no known prior medical issues and was in good health acc…

emergency medicinecardiology
NSWhome2016-01-20

Inquest into the death of Leonie Margaret Philpott

47y · Female·unascertained - natural causes

Leonie Margaret Philpott, a 47-year-old bush regeneration worker, was found deceased in bed on Christmas Day 2014. Despite a thorough three-cavity autopsy and comprehensive investigations including microscopic tissue exa…

pathologygeneral practiceibuprofen
VIC2020-01-29

Finding into death of Prisoner A

55y · Male·Ischaemic heart disease in a man with multiple system atrophy (Parkinsonian type…

A 55-year-old man with ischaemic heart disease and multiple system atrophy (MSA) died suddenly in custody from natural causes. He presented with tremors and collapse in 2017, and was appropriately diagnosed with MSA Park…

cardiologyneurologylevetiracetam
WA2024-12-23

Inquest into the Death of Frank MIKHAIL

68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…

Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…

respiratory medicineemergency medicinediagnosticcommunicationamitriptyline
VIChome2013-06-28

Finding into death of Walter Leonard Colyer

63y · Male·Ischaemic heart disease and aortic stenosis

Walter Leonard Colyer, a 63-year-old man with intellectual disability living in supported residential care, died suddenly from ischaemic heart disease and aortic stenosis while visiting his sister. He had known aortic st…

cardiologygeneral practice
NSW2023-08-23

Inquest into the death of Stefan Wakeman

55y · Male·ischaemic heart disease

Stefan Wakeman, aged 55, died of ischaemic heart disease while in custody at Metropolitan Remand and Reception Centre on 9 June 2019. Autopsy revealed significant coronary artery narrowing (40-50% to 70-80%) with emphyse…

correctional healthgeneral practicemethadone
QLDcommunity2017-09-14

John, Timothy

22y · Male·Hanging

Timothy John, age 22, died by hanging 8 days after commencing varenicline (Champix) for smoking cessation. He had a documented history of depression, anxiety, and substance abuse, with prior attempted …

general practicepsychiatrydiagnosticcommunicationvarenicline
167815

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