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VIChospital2019-06-07

Finding into death of Maria Kerr

60y · Female·Pulmonary thromboembolism in a woman recovering from a fractured right ankle

Maria Kerr, a 60-year-old woman with obesity and thalassemia minor, died from pulmonary thromboembolism 33 days after sustaining a fractured ankle. An administrative error resulted in her urgent orthopaedic follow-up app…

emergency medicineorthopaedic surgerysystemcommunication
VIChospital2019-06-06

Finding into death of J Y

24y · Female·injuries sustained in descent from height

A 24-year-old woman with intellectual disability and borderline personality disorder died from injuries sustained in descent from height from a sixth-floor balcony. She had threatened suicide from the same balcony on 8 M…

psychiatryemergency medicinecommunication
VICaged care2019-05-30

Finding into death of S B

87y · Male·Complications of head injuries in setting of dementia

An 87-year-old man with vascular dementia died from complications of head injuries sustained in assaults by a fellow nursing home resident. The deceased had a documented tendency to wander and enter other residents' room…

geriatric medicineforensic medicinesystemcommunicationclopidogrel
VIChome2019-05-29

Finding into death of DQ

2y · Female·Carbon monoxide toxicity

Two young sisters (aged 2 years 9 months and 1 year 9 months) died from carbon monoxide toxicity following a house fire in their shared bedroom. A stuffed toy ignited against an electric heater, causing a slow-burning fi…

systemcommunication
VIChome2019-05-29

Finding into death of LQ

2y · Female·Carbon monoxide toxicity

Two young sisters (DQ aged 2 years 9 months and LQ aged 1 year 9 months) died from carbon monoxide toxicity following a house fire caused by a stuffed toy igniting in front of an electric heater. The fire was in their be…

system
VICmental health2019-05-17

Finding into death of Thi Ha Do

42y · Female·Incised injury to the neck

A 42-year-old woman with depression and suicidal ideation died by self-inflicted neck laceration while admitted to a psychiatric inpatient unit. She had been assessed as low risk and placed on 30-minute observations. Cli…

psychiatryforensic medicinesystemcommunicationmirtazapine
VIChospital2019-05-17

Finding into death of Mabel Grace Ellen Pritchard

90y · Female·Hospital acquired pneumonia in the setting of recent fractures of neck of humeru…

A 90-year-old woman with multiple comorbidities residing in aged care sustained a hip fracture from a fall in January 2018. Following surgical repair and initial hospital treatment, she was transferred to a rehabilitatio…

geriatric medicineorthopaedic surgerysystempiperacillin/tazobactam
VICcommunity2019-05-15

Finding into death of Desmond John Watson

65y · Male·Neck trauma and severe ischaemic heart disease in the setting of immersion

A 65-year-old experienced kneeboarder died from neck trauma and severe ischaemic heart disease following immersion at a surf competition. He fell from his board during the B Grade Final in challenging conditions at Gunna…

forensic medicineemergency medicinesystem
VIChospital2019-05-10

Finding into death of Simon Smith

22y · Male·acute blood loss from incised injuries to left forearm

Simon Smith, a 22-year-old with end-stage renal failure requiring dialysis and complex comorbidities, died by suicide during hospitalization. Despite multiple psychiatric assessments finding he had capacity to make treat…

psychiatrynephrologycommunicationsystemtemazepam
VIChospital2019-05-09

Finding into death of Darren Templeton

51y · Male·pulmonary thromboembolus secondary to left deep vein thrombosis

Darren Templeton, a 51-year-old man with obesity (BMI 31.5), died of pulmonary thromboembolism and left deep vein thrombosis six days after undergoing left knee arthroscopy. Critical clinical lessons: (1) VTE risk assess…

orthopaedic surgeryanaesthesiasystemdiagnosticaspirin
VICcommunity2019-04-29

Finding into death of William Willms

63y · Male·Unknown

William Willms disappeared on 23 July 1973 at age 63 after boarding a bus to Lilydale railway station. He had recently self-discharged from psychiatric admission for endogenous depression and suicidal ideation. Despite e…

psychiatrygeneral practicesystemdelay
VIChospital2019-04-24

Finding into death of Dennis John Wright

72y · Male·head injuries sustained in a fall from a ladder

A 72-year-old man died from unsurvivable head injuries sustained in a fall from a domestic ladder. He was climbing down from his roof when he slipped and fell backwards onto concrete. Despite rapid helicopter transport t…

trauma surgeryneurosurgerymorphine
VICcommunity2019-04-16

Finding into death of Sophie Margery Nicholas

27y · Female·Injuries sustained in motor vehicle incident (pedestrian)

Sophie Nicholas, aged 27, died by suicide after being struck by a truck while walking along a road at 1:30am on 15 September 2016. She had longstanding borderline personality disorder (BPD) and alcohol dependency, with f…

psychiatryaddiction medicinecommunicationsystemalcohol
VIC2019-04-15

Finding into death of Nick Falos (formerly known as Nikolaos Falieros)

58y · Unknown·Unknown - suspected foul play

Nick Falos, aged 58, was last seen on 14 March 2003 and subsequently reported missing in November 2018. A coronial investigation was undertaken following formal report to the coroner as a suspected death. Detective inves…

VIChospital2019-04-05

Finding into death of Richard Alan Jones

68y · Male·exacerbation of congestive cardiac failure and aspiration pneumonia on a backgro…

Richard Alan Jones, a 68-year-old man with cerebral palsy, intellectual disability, epilepsy, and cardiac disease, presented to Austin Hospital in respiratory failure from congestive cardiac failure exacerbation and aspi…

cardiologyemergency medicinemorphine
VIChospital2019-04-04

Finding into death of Isabella Estelle Rees

1y · Female·Gastrointestinal haemorrhage due to aorto-oesophageal fistula caused by lodged b…

Isabella Rees, aged 14 months, presented to Sunshine Hospital ED four times over 19 days with fever, vomiting and later haematochezia. A button battery lodged in her oesophagus caused progressive caustic injury leading t…

emergency medicinepaediatricsdiagnosticcommunicationondansetron
VICcommunity2019-04-03

Finding into death of Frank Hulland

77y · Male·Chest and pelvic injuries sustained in a farming incident

A 77-year-old farmer died from chest and pelvic injuries sustained in a farm machinery incident. Mr Hulland was operating a Ford utility with an attached hydraulic trailer in low gear without a driver, a common practice …

forensic medicinegeneral practicesystem
VIChospital2019-04-02

Finding into death of Bevan John Stevens

73y · Male·Aspiration pneumonia complicating sigmoid volvulus in a man with Down syndrome

A 73-year-old man with Down syndrome and a history of dysphagia with recurrent aspiration pneumonia presented with drowsiness, shortness of breath, and was found to have sigmoid volvulus and left lower lobe consolidation…

general medicinegastroenterologyceftriaxone
VIChospital2019-03-29

Finding into death of Brian Maher

44y · Male·Bilateral pneumonia in a man with Downs Syndrome

Brian Maher, a 44-year-old man with Down syndrome, died from bilateral pneumonia following rapid clinical deterioration. He presented to hospital on 2 December 2017 with dyspnoea and was admitted to the emergency departm…

emergency medicinerespiratory medicine
VIChospital2019-03-28

Finding into death of Kerri Michelle Moore

55y · Female·Aspiration pneumonia in a woman with epilepsy and intellectual disability

Kerri Michelle Moore, a 55-year-old woman with intellectual disability, epilepsy, and progressive neurological deficit, died from aspiration pneumonia. She was admitted with status epilepticus, treated with antibiotics a…

intensive carerespiratory medicine

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