Coronial
VIChospital2012-10-26

Finding into death of Rodney David Keegan

41y · Male·Cardiomyopathy in a setting of acute abdomen

Rodney David Keegan, a 41-year-old man with intellectual disability, epilepsy, psychosis, and prior cardiac surgery, was admitted to hospital following a fall. He developed acute abdominal pain with free fluid on imaging…

cardiologyintensive carewarfarin
NSW2016-12-07

Inquest into the death of Michael GAVANAS

50y · Male·Acute methamphetamine toxicity

…phetamine toxicity can rapidly cause fatal complications including arrhythmias, myocardial infarction, and stroke, particularly in patients with pre-existing cardiac disease. Recognition of acute stimulant toxicity in th…

toxicologycardiologymethamphetamine
VIChospital2020-02-28

Finding into death of Keith Walter Sharp

63y · Male·Cerebral infarction complicating vertebral artery dissection following motor veh…

…to Royal Melbourne Hospital for possible interventional radiology might have offered limited benefit given stroke timing and logistics, systemic failures were identified: poor documentation, inadequate senior supervision…

emergency medicineradiologydelaydiagnosticaspirin
VIChospital2014-07-16

Finding into death of Beverly Davidge

78y · Female·Acute gastrointestinal haemorrhage

Ms Beverly Davidge, a 78-year-old woman with intellectual disability living in residential care, died from acute gastrointestinal haemorrhage in hospital. She presented initially with haematemesis and melaena on 11 Novem…

gastroenterologygeneral medicine
TAShome2017-01-23

Coroner's Finding: Mordha, Debra Christine

58y · Female·mixed drug toxicity

A 58-year-old retired nurse died from mixed drug toxicity involving tramadol, amitriptyline, and venlafaxine, all found at above-therapeutic concentrations. She had multiple chronic conditions including Addison's disease…

general practicepathologytramadol
SAhospital2022-03-30

Coroner's Finding: Commisso, Salvatore

70y · Male·advanced left frontal glioblastoma (operated)

…soner died from advanced left frontal glioblastoma. The tumour was identified when he presented with acute stroke-like symptoms (facial droop, weakness, confusion) in July 2018 while imprisoned. He underwent debulking su…

neurosurgeryoncologyfluticasone/salmeterol
SAhospital2020-06-11

Coroner's Finding: GRUNDY Hugh Keightly

65y · Male·general inanition on a background of advanced fronto-temporal dementia

… dementia. He had a progressive decline from 2002, with formal diagnosis in 2013, complicated by seizures, stroke, and behavioural aggression requiring escalating levels of care. He was managed under a Mental Health Act …

psychiatrygeriatric medicine
SAhospital2020-07-16

Coroner's Finding: HANAN Desmond George

90y · Male·pneumonia complicating fractured right neck of femur (operated) on a background …

A 90-year-old man with prior stroke, hypertension, and cerebrovascular disease was admitted to hospital following a fall with right femoral ne…

orthopaedic surgerypsychiatryantibiotics
QLDhome2014-07-18

Bowling, Dianne Judith

59y · Female·Mixed drug toxicity, with metoprolol at toxic level; coronary atherosclerosis as…

Dianne Bowling, a 59-year-old woman with a 40-year history of bipolar disorder, died from mixed drug toxicity involving a toxic level of metoprolol. She had a history of three previous overdoses and was under community m…

psychiatrygeneral practicecommunicationsystemmetoprolol
SA2020-05-08

Coroner's Finding: ENCHEFF Dragni

74y · Male·metastatic adenocarcinoma of the lung on a background of ischaemic heart disease…

A 74-year-old prisoner with metastatic lung cancer, ischaemic heart disease, peripheral vascular disease, and diabetes died at Yatala Labour Prison Health Centre. He was diagnosed with advanced lung cancer in April 2016 …

correctional healthrespiratory medicine
SAaged care2019-04-15

Coroner's Finding: CATALANO Fernanda

85y · Female·ischaemic heart disease with renal failure

Fernanda Catalano, 85 years old, died of ischaemic heart disease with renal failure at Lyell McEwin Hospital. She had suffered an unwitnessed fall at her aged care facility on 20 April 2016, was transferred to hospital w…

geriatric medicineemergency medicinequetiapine
VICaged care2014-12-15

Finding into death of Terence Joseph Roadley

63y · Male·Complications of disseminated tumour (primary site unknown)

Terence Joseph Roadley, aged 63, died from complications of disseminated carcinoma with unknown primary site in a palliative care setting. He had intellectual disability and was under state care via a Supervised Treatmen…

palliative caregeneral practicemetoclopramide
VICmental health2016-04-20

Finding into death of Chris Pravin Prasad

51y · Male·undetermined natural causes

Chris Prasad, a 51-year-old involuntary psychiatric inpatient with schizoaffective disorder, diabetes type 2, hypertension, and obesity (BMI 30.8), was granted day leave on 17 January 2013 during extreme heat (38°C) at C…

psychiatrygeneral medicinemedicationdiagnosticpaliperidone
TAShospital2021-08-23

Coroner's Finding: Cooper, Melanie Sarah 2021 TASCD 475

51y · Female·embolic infarcts complicating infective endocarditis

Melanie Sarah Cooper, aged 51, died from embolic infarcts complicating infective endocarditis secondary to chronic intravenous opioid use. She presented with severe physical deterioration over three days including swolle…

intensive careinfectious diseasesdelaymorphine
WAcommunity2020-06-02

Inquest into the Suspected Death of Wombat NGURRAKATA

54y · Male·Open Finding—unable to determine manner or cause of death

… voluntary disappearance implausible. The coroner could not determine manner of death—natural causes (heat stroke, asthma attack) remain possible, though the deceased's family expressed concerns about potential foul play…

SAhospital2003-03-04

Coroner's Finding: VASSALLO Virginia

59y · Female·multiple cerebral infarction due to infective endocarditis

…t day more unwell and was eventually started on antibiotics after 30+ hours, but suffered multiple embolic strokes from cardiac vegetations and died. While earlier diagnosis may not have changed outcome due to large vege…

emergency medicinecardiologydiagnosticdelayparacetamol/codeine
QLDcommunity2016-04-20

Newport, Glenn Richard

38y · Male·cardiac arrest precipitated by dilutional hyponatraemia

A 38-year-old construction worker died from dilutional hyponatraemia after working in extreme heat (>40°C) on a concrete formwork project in rural Queensland. He developed symptoms of heat injury at the worksite and was …

occupational and environmental healthparamedicinediagnosticcommunication
VIChospital2024-11-13

Finding into death of Angela Bella Kettyle

53y · Female·Aspiration pneumonia complicating large bowel obstruction due to faecal impactio…

Angela Kettyle, a 53-year-old NDIS participant with significant comorbidities including Type II diabetes, cirrhosis, and chronic constipation, died from aspiration pneumonia complicating large bowel obstruction due to fa…

gastroenterologygeneral medicinemorphine
QLD2025-12-01

Non-Inquest findings into the deaths of Ashley Pangana Morris and Humbereto Ferreira Leite

Male·Multiple injuries due to or as a consequence of concrete wall collapse

…incident. D'Alessandro was charged with manslaughter but proceedings were discontinued after he suffered a stroke in 2019. The principal contractor, Criscon, was successfully prosecuted and fined $625,000.

occupational and environmental healthproceduralsystem
WAhospital

Inquest into the Death of Robin David MACARTNEY

62y · Male·bronchopneumonia in a man receiving terminal palliative care for metastatic carc…

Robin David Macartney, a 62-year-old prisoner serving a life sentence for murder, died from bronchopneumonia secondary to metastatic colon cancer. He was diagnosed with sigmoid colon cancer in December 2006 but refused s…

oncologygeneral surgery
1891012

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