Coronial

168 results for terminal illness

SAhospital2000-04-12

Coroner's Finding: RUSSELL Brian Edward

80y · Male·bronchopneumonia complicated by morphine toxicity

An 80-year-old man with terminal liver disease died from bronchopneumonia complicated by morphine toxicity following a medication administ…

palliative caregastroenterologymedicationproceduralmorphine
VIChome

Finding into death of Nathan Carl Skewes

31y · Male·mixed drug toxicity

Nathan Carl Skewes, age 31, died on 10 June 2012 from mixed drug toxicity involving his deceased wife's powerful palliative medications (fentanyl, ketamine, hydromorphone, morphine, codeine, paracetamol, cannabinoids). H…

systemfentanyl
SAhospital2015-08-27

Coroner's Finding: JONES John David

65y · Male·Multi-organ failure in a man with an ischaemic right leg treated with opioids

…h multiple comorbidities; and the importance of family communication regarding mental health detention in terminal illness.

emergency medicinerespiratory medicineopioids
WAhospital2021-08-06

Inquest into the Death of Hassan Mohamed YOUSSEF

60y · Male·Complications of gastrointestinal haemorrhage due to cirrhosis of the liver seco…

…with no issues contributing to his death. While the Royal Prerogative of Mercy was not considered despite terminal illness status, parole denial was appropriate given community safety concerns. Clinical lessons include t…

gastroenterologyhepatology
QLDhospital2024-12-16

Inquest into the death of Shane Anthony May

61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…

Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory…

emergency medicinerespiratory medicineamlodipine
NSW2018-02-09

Inquest into the death of Ian James McAuliffe

67y · Male·metastatic prostate cancer

Ian McAuliffe, a 67-year-old man serving a custodial sentence, died from metastatic prostate cancer. The case examined whether his cancer treatment as a prisoner was adequate compared to community care. His oncologist Dr…

oncologypalliative caregoserelin
SA2019-05-14

Coroner's Finding: SFYRIS Michael

50y · Male·carcinomatosis due to metastatic, poorly differentiated renal cell carcinoma unc…

Michael Sfyris, a 50-year-old prisoner, died of metastatic renal cell carcinoma in April 2016. A CT scan performed in September 2015 revealed an adrenal lesion but the radiology report was misfiled and not reviewed for 2…

oncologyradiologysystemdelaypazopanib
WA2005-03

Inquest into the Death of Allan Chapman

75y · Male·Metastatic Lung Carcinoma

Allan Chapman, a 75-year-old sentenced prisoner, died of metastatic lung carcinoma on 4 April 2004 at Murdoch Community Hospice. He presented with lethargy and dysphonia in February 2004, leading to prompt chest imaging …

palliative carerespiratory medicinesystem
WAhospital2022-02-14

Inquest into the Death of Jeffrey Lee STRETTLES

52y · Male·complications in association with advanced malignancy (hepatocellular carcinoma)…

… Department of Justice failed to prepare a briefing note to the Minister when Strettles was classified as terminally ill (Stage 3), preventing consideration for compassionate release under the Royal Prerogative of Mercy.…

gastroenterologyoncologysystemledipasvir
NThospital2016-04-22

Inquest into the death of Bundy Namarnyilk

56y · Male·Acute bronchopneumonia secondary to locally advanced, poorly differentiated squa…

A 56-year-old Aboriginal man died in custody from bronchopneumonia secondary to metastatic hypopharyngeal squamous cell carcinoma. He first presented with sore throat in February 2014 and was referred to ENT clinic in Ap…

ENT surgeryoncology
VICcommunity2025-08-27

Finding into death of Conan James Smith

37y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

A 37-year-old man died in a deliberate head-on motor vehicle collision three days after his partner died from metastatic cancer. He was the sole carer for his 7-year-old son with autism and intellectual disability. The c…

psychiatrygeneral practicecommunicationdelaymirtazapine
VIChome2021-07-30

Finding into death of GAMcM

45y · Male·Hanging

…g significant workplace stress. He had consulted his GP in October 2014 regarding grief over his mother's terminal illness and was prescribed sleeping tablets. He was diagnosed with depression in March 2015, started on s…

general practicepsychologydelaysertraline
VICcommunity2025-08-27

Finding into death of Harley James Smith

7y · Male·multiple injuries sustained in a motor vehicle collision (passenger)

…ng acute suicide risk in distressed individuals and the importance of comprehensive family support during terminal illness. Critical clinical lessons include recognizing warning signs of acute decompensation following be…

paediatricspsychiatrycommunicationsystemmirtazapine
TAShome2015-10-02

Coroner's Finding: Ms G de-identified

Female·hanging (suicide)

Ms G, a woman in her forties with bipolar II disorder, generalised anxiety disorder, and severe alcohol dependence, died by suicide in November 2014. She had been admitted to hospital six times for detoxification and men…

psychiatryaddiction medicinesystemalcohol
NThospital2014-02-13

Inquest into the death of Peter Clarke

55y · Male·bronchopneumonia complicating metastatic carcinoma of the right lung, with emphy…

Peter Alexander Clarke, a 55-year-old Aboriginal man and serving prisoner, died of bronchopneumonia complicating metastatic lung carcinoma with emphysema, coronary atherosclerosis and chronic pancreatitis. He presented t…

emergency medicineintensive carediagnostic
WAhospital2012-05-31

Inquest into the Death of GARRETT

52y · Male·HIV infection complicated by basal and squamous cell carcinoma of the head and n…

…atment and care provided was reasonable. Key recommendations focused on developing protocols for managing terminally ill prisoners, including NFR documentation, removal of restraints, and dedicated medical facilities.

emergency medicineintensive careheparin
NTaged care2010-07-05

Inquest into the death of Desmond Waight

81y · Male·bronchopneumonia

An 81-year-old man with dementia, congestive cardiac failure, chronic lung disease and hip fractures died of bronchopneumonia four days after discharge from palliative care to a nursing home. While an administrative erro…

palliative caregeneral practicemedicationsystemamoxicillin/clavulanate
ACThome2026-03-10

Inquest into the death of [Redacted] Williams

Female·sodium nitrite poisoning

… matters of public safety and no preventable errors. The case highlighted gaps in end-of-life options for terminally ill patients without access to VAD, leading to the ACT subsequently implementing a VAD scheme in Novemb…

palliative carepsychiatrysodium nitrite
WAhospital2022-03-03

Inquest into Death of Van Tho NGUYEN

59y · Male·metastatic lung cancer, with palliation

…g the Department of Justice policy requiring active steps to facilitate bail application discussions with terminally ill prisoners (Stage Three or Four). The policy steps should have commenced in August 2019 when his sta…

oncologypalliative caresystemcommunicationchemotherapy agents
SAprison2023-11-10

Coroner's Finding: Trotta, Giovanni

58y · Male·acute bronchopneumonia

…en saturation, or history were taken, and no follow-up assessment was arranged; (6) three days of obvious illness (2-5 July) without proactive medical intervention was indefensible; (7) procedural clarity in medical eme…

emergency medicinerespiratory medicinediagnosticcommunicationclozapine
1789

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