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VIChospital2021-09-21

Finding into death of AH

37y · Male·Mixed Drug Toxicity (Oxycodone, Quetiapine, Pregabalin and Clonazepam)

A 37-year-old man died from mixed drug toxicity (oxycodone, quetiapine, pregabalin, clonazepam) after ingesting unknown quantities of his own medications in an ED. He presented with trauma symptoms four days post-motor v…

emergency medicinetoxicologydiagnosticcommunicationoxycodone
VIChospital2021-08-16

Finding into death of David John Main

54y · Male·Toxic leukoencephalopathy (of uncertain aetiology)

David Main, 54, died from toxic leukoencephalopathy of uncertain aetiology following a ketamine-assisted oxycodone detoxification at Beleura Private Hospital. He had chronic pain from multiple injuries and opioid depende…

pain medicineanaesthesiaketamine
TAShospital2021-08-13

Coroner's Finding: Mrs M

Female·multi-organ failure

Mrs M died from multi-organ failure following recurrent intra-abdominal sepsis and surgical complications after endoscopic duodenal perforation in June 2019. During resection of a duodenal adenoma, perforation occurred r…

gastroenterologygeneral surgerydiagnostic
VIChospital2021-07-20

Finding into death of Barry Brown

56y · Male·Internal blood loss, complications arising from laparoscopic cholecystectomy

Barry Brown, a 56-year-old man, died from internal bleeding after laparoscopic cholecystectomy due to critical systemic failures in post-operative care and diagnosis. Following hypotension at 7:30pm, nursing staff failed…

general surgeryintensive carediagnosticcommunicationnoradrenaline
TAShospital2021-07-02

Coroner's Finding: HB

8y · Male·acute exacerbation of chronic asthma

An 8-year-old boy with undertreated chronic asthma presented to North West Regional Hospital with acute exacerbation. Initial assessment underestimated severity. Despite initial improvement with salbutamol, ipratropium a…

paediatricsemergency medicinediagnosticcommunicationfluticasone/salmeterol
TAShospital2021-05-24

Coroner's Finding: Wade, Neville Ernest

80y · Male·acute myocardial ischaemia due to coronary atherosclerosis

Mr Wade, aged 80, died from acute myocardial infarction following knee surgery. On postoperative day 3, he developed chest symptoms, elevated troponin, and hypoxia. An ECG was performed showing acute anterior myocardial …

cardiologygeneral surgerydiagnosticcommunication
WAhospital2021-03-26

Inquest into the Death of Cyril CHURCHILL

68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…

Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treatin…

general surgeryanaesthesiadiagnosticcommunication
WAhospital2020-12-01

Inquest into the Death of Tahlia Rose BEMBRIDGE

4y · Female·volvulus of the large intestine

Tahlia Rose Bembridge, a 4-year-old with Down syndrome and prior mid-gut volvulus, presented to Bunbury Hospital ED with vomiting and abdominal pain on 1 October 2015. Initial assessment excluded acute bowel obstruction.…

paediatricsemergency medicinecommunicationdelay
NSWhospital2020-11-27

Inquest into the death of Makushla NIKOLAEVSKY

43y · Female·pulmonary embolism

A 43-year-old woman died from pulmonary embolism after hysteroscopy for investigation of heavy menstrual bleeding. Following the procedure, she developed left leg swelling on day 3. A Venous Doppler Ultrasound was perfor…

gynaecologyvascular surgerydiagnosticpossibly proceduralenoxaparin
VIChospital2020-11-25

Finding into death of Eoghan Jerome Arnold

42y · Male·Hypoxic ischaemic brain injury secondary to cardiac arrest caused by massive pul…

A 42-year-old man died from hypoxic ischaemic brain injury following cardiac arrest due to a massive pulmonary embolism. He sustained a tibial fracture in a motor vehicle accident and underwent external fixation. He deve…

orthopaedic surgeryanaesthesiasystemenoxaparin
NSWhospital2020-11-20

Inquest into the death of Melissa Stokes

49y · Female·Fatal Cardiac Arrhythmia

Melissa Stokes, 49, died from a fatal cardiac arrhythmia one day after successful abdominal hysterectomy and sling surgery. The coroner found the cause was not opioid-induced respiratory depression despite post-operative…

anaesthesiagynaecologycommunicationdelaytramadol
VICcommunity2020-11-19

Finding into death of Zachary Matthew Bryant

Unsurvivable traumatic injuries from blunt force impact with motor vehicle; pred…

On 20 January 2017, James Gargasoulas drove a stolen vehicle through Bourke Street Mall in Melbourne's CBD, striking 33 pedestrians and fatally injuring 6: Matthew Poh Chuan Si (33), Thalia Hakin (10), Yosuke Kanno (25),…

emergency medicinetrauma surgery
SAhospital2020-11-03

Coroner's Finding: MARSHALL Daryl Grant

61y · Male·hospital acquired pneumonia complicating aorto-femoral bypass surgery for periph…

A 61-year-old man with peripheral vascular disease, alcohol dependence, and heavy smoking history underwent aorto-femoral bypass surgery. Post-operatively he developed hospital-acquired pneumonia, delirium from alcohol w…

vascular surgeryintensive care
WAhospital2020-10-19

Inquest into the Death of Renee Desiree RUYZING

21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg

A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…

orthopaedic surgeryemergency medicinediagnosticmedicationenoxaparin
VIChospital2020-10-19

Finding into death of BABY FF

2y · Male·Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstr…

A term infant died on day 2 of life from hypoxic-ischaemic encephalopathy and intracranial haemorrhage following obstructed labour requiring emergency caesarean section. The mother presented in spontaneous labour at 39 w…

obstetricsneonatologymonitoringcommunicationoxytocin
VIChospital2020-10-13

Finding into death of BABY C

0y · Male·Myocarditis

Baby C, a 5-month-old infant, died from myocarditis (viral heart inflammation) after presenting to Sunshine Hospital Emergency Department with fever, breathing difficulty, and cyanosis. He waited 1 hour 52 minutes before…

emergency medicinepaediatricsdiagnosticdelayparacetamol
SAhospital2020-10-12

Coroner's Finding: USHER Peter Michael

56y · Male·hypoxic ischaemic encephalopathy following insulin and benzodiazepine overdose

A 56-year-old man with depression, known to close friends but not formally disclosed to healthcare providers, deliberately ingested temazepam tablets accumulated over time and insulin stolen from his mother on 10-11 Nove…

anaesthesiapsychiatrytemazepam
TASmental health2020-10-09

Coroner's Finding: Le Roy, Carole Ann

40y · Female·hypoxic encephalopathy due to asphyxia from hanging

A 40-year-old woman with extensive mental health history including OCD, complex trauma, severe depression, and recurrent suicidal ideation was admitted to an open psychiatric unit after expressing suicidal intent. Despit…

psychiatryintensive carediagnosticsystem
NSWhospital2020-10-02

Inquest into the death of Madeline Newcombe

63y · Female·Pulmonary thromboembolism

A 63-year-old woman died from pulmonary thromboembolism within 24 hours of bilateral total knee arthroplasty despite aspirin and sequential compression devices. The surgeon assessed her as standard risk and did not presc…

orthopaedic surgeryanaesthesiacommunicationdiagnosticaspirin
VIChospital2020-09-29

Finding into death of Nicola Deleo

91y · Male·Complications following cardiac arrest in the setting of anaesthetic induction d…

A 91-year-old man with COPD, asthma, and previous cardiac arrest from suxamethonium died from complications following anaphylaxis to rocuronium during anaesthetic induction for emergency small bowel obstruction surgery. …

anaesthesiageneral surgerycommunicationsystemrocuronium
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