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VICaged care2022-11-23

Finding into death of Lucio Chiussi

89y · Male·septicaemia due to infected groin wound, femoropopliteal bypass in a man with mu…

An 89-year-old man with multiple comorbidities (diabetes, peripheral vascular disease, heart failure) developed a groin wound infection following femoropopliteal bypass surgery while residing in aged care. The wound dete…

geriatric medicinevascular surgerydiagnosticcommunicationoral antibiotics
VIChospital2022-11-14

Finding into death of Gregory Bernard Duffy

55y · Male·Urosepsis and pneumonia, with contributing factor of Down syndrome

Gregory Duffy, a 55-year-old man with Down syndrome and intellectual disability living in supported accommodation, died from urosepsis and pneumonia following recurrent urinary tract infections. He had multiple UTIs duri…

infectious diseasesintensive careinsulin
SAhospital2022-10-27

Coroner's Finding: Rentoulis Dimitrios

79y · Male·Iatrogenic right ventricular injury complicating drainage of pericardial collect…

A 79-year-old man died from iatrogenic right ventricular injury sustained during attempted drainage of a post-operative pericardial effusion following coronary artery bypass grafting. During a minimally invasive sub-xiph…

cardiothoracic surgeryanaesthesiaproceduralwarfarin
NSWhospital2022-10-14

Inquest into the death of Malouvailoa Tafau

20y · Male·cardiac arrest due to complications of infective endocarditis against a backgrou…

Maluovailoa Tafau, a 20-year-old man in custody, died from cardiac arrest due to infective endocarditis complicated by rheumatic heart disease. He had submitted two patient self-referral forms (September 2016 and Februar…

cardiologyinfectious diseasesdiagnosticcommunicationflucloxacillin
TASaged care2022-10-13

Coroner's Finding: Krushka, Robert

66y · Male·sepsis following bacteraemia caused by transurethral catheter insertion

A 66-year-old man with severe dementia and multiple comorbidities died from sepsis following bacteraemia after a routine indwelling urinary catheter change at a nursing home. The catheter insertion was traumatic, resulti…

geriatric medicineemergency medicineproceduralsystem
VIChospital2022-10-11

Finding into death of Mr H

73y · Male·Infectious Exacerbation of Chronic Obstructive Airways Disease with the Contribu…

Mr H, a 73-year-old man with chronic obstructive airways disease and Lewy body dementia, was admitted to hospital on 6 January 2021 following a psychiatric incident and was found to have pneumonia and severe infection. H…

geriatric medicinepsychiatrydelay
VIChospital2022-10-03

Finding into death of Travis Jack Blows

15y · Male·pneumonia in the setting of cerebral palsy and epilepsy

Travis Blows, a 15-year-old with cerebral palsy and difficult-to-control epilepsy, died from pneumonia after a prolonged PICU admission. He presented to ED multiple times in the months before death with seizures and feve…

neurologyintensive careclobazam
VIChospital2022-09-15

Finding into death of Jennifer Anne Jones

62y · Female·Sepsis secondary to lower respiratory tract infection

Jennifer Anne Jones, a 62-year-old woman with Down's syndrome, dementia, dysphagia, and epilepsy living in a disability care facility, died from sepsis secondary to lower respiratory tract infection. She presented with h…

general practiceemergency medicinebetamethasone
VIChospital2022-08-29

Finding into death of Helen Welsh

63y · Female·Escherichia coli septicaemia in a lady with multiple comorbidities

Helen Welsh, 63, died from E. coli septicaemia with multiple comorbidities. She presented with respiratory symptoms and underwent bronchoscopy. On discharge day, she deteriorated with fever, altered consciousness, and hy…

cardiothoracic surgeryemergency medicinedelaydiagnosticcarbimazole
NSWhospital2022-08-17

Inquest into the death of Michael Quinn

31y · Male·sepsis due to urosepsis and pneumonia on a background of C3 incomplete tetrapleg…

Michael Quinn, a 31-year-old quadriplegic inmate, died from sepsis secondary to urosepsis and pneumonia. He had C3 incomplete tetraplegia from a self-inflicted stab wound in 2013 and was serving a 20-year sentence. An in…

urologyinfectious diseases
VIChome2022-08-15

Finding into death of John Disley

80y · Male·Multiple injuries post fall from a roof

An 80-year-old man died from multiple injuries sustained in a fall from a roof while cleaning gutters at home. He fell approximately 2 metres from a ladder, sustaining rib, pelvis, and spine fractures, plus vertebral art…

trauma surgerycardiologyaspirin
VICaged care2022-08-01

Finding into death of Mr CLX

85y · Male·Incised wounds to the wrist

An 85-year-old man with myelodysplasia and severe hip pain from an ischiorectal abscess died from incised wrist wounds sustained in a nursing home while in palliative care. He had expressed wishes to die, discussed eutha…

palliative caregeriatric medicinesystemcommunicationoxycodone
TAShome2022-06-28

Coroner's Finding: Mansell, Sean Erwin

57y · Male·Undetermined; possible sudden unexpected death in epilepsy (SUDEP) with competin…

Sean Erwin Mansell, aged 57, was found deceased in his home in Kingston, Tasmania on 24 November 2021. The cause of death could not be determined but was possibly sudden unexpected death in epilepsy (SUDEP), with competi…

forensic medicineneurologysodium valproate
VIChospital2022-06-16

Finding into death of Dana John Walter

68y · Male·Aspiration pneumonia (due to cerebral palsy and dysphagia)

Dana John Walter, 68, died of aspiration pneumonia following cerebral palsy and severe dysphagia. He was readmitted to hospital on 11 August 2020 with acute respiratory distress three days after discharge. Despite thicke…

emergency medicinerespiratory medicinesalbutamol
NSWhospital2022-05-30

Inquest into the death of Alex BRAES

18y · Male·Multi organ failure due to sepsis from a Group A streptococcus infection

Alex Braes, an 18-year-old from Broken Hill NSW, died of multi-organ failure due to Group A streptococcus sepsis. He presented to Broken Hill Base Hospital three times over 24 hours with knee pain that progressed to seps…

emergency medicineinfectious diseasessystemdelayceftriaxone
TAShome2022-05-27

Coroner's Finding: TS de-identified

47y · Female·Traumatic closed head injury likely sustained in a fall from standing

TS, a 47-year-old woman with a 18-year history of anorexia nervosa, bulimia, and severe alcoholism, died from a traumatic closed head injury sustained in a fall from standing. At autopsy, blood alcohol concentration was …

emergency medicinegeneral practicecommunicationsystemalcohol
SAhospital2022-04-14

Coroner's Finding: Esposito, Pasquale

76y · Male·combined effects of acute myocardial infarction and urosepsis

Pasquale Esposito, age 76, died in custody at Lyell McEwin Hospital from combined acute myocardial infarction and urosepsis. He had extensive cardiac history including prior MI, CABG, COPD, and recent stent placement. On…

cardiologyinfectious diseasesantibiotics
TAShome2022-03-23

Coroner's Finding: Stephens, Vicki Lavinia

65y · Female·klebsiella pneumonia sepsis and rhabdomyolysis after a fall at home

A 65-year-old woman with multiple chronic conditions including COPD, ischaemic heart disease, and alcoholic hepatitis fell at home and remained on the floor for approximately 2 hours before ambulance arrival. She present…

emergency medicineintensive care
TAShospital2022-03-18

Coroner's Finding: Campbell, Nancy

82y · Female·sepsis with septic shock due to ascending cholangitis

Nancy Campbell, an 82-year-old woman with delusional disorder subject to mental health treatment orders, died from sepsis with septic shock due to ascending cholangitis. She had gallstones identified on MRCP during psych…

psychiatrygeneral medicineantipsychotic medication
VICaged care2022-01-14

Finding into death of Margaret Lillian Watkins

84y · Female·Complications of pelvic fractures sustained in a traumatic incident

An 84-year-old woman with dementia died from complications of pelvic fractures sustained when another dementia-affected resident pushed her during an altercation over food in an aged care facility. She developed bilatera…

geriatric medicineemergency medicinesystemdelaymorphine
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