Coronial
VIChospital2011-10-20

Finding into death of Andrew Westley

56y · Male·Cardiogenic shock, end stage ischemia due to chemo related cardiomyopathy, fulmi…

…ausing adhesions), and organ procurement from far North Queensland. Post-operatively, he required prolonged ECMO, IABP, and biventricular assist devices but developed VRE sepsis, aspergillus infection, and multi-organ fa…

cardiothoracic surgerytransplant medicinedelayvancomycin
VIChospital2020-05-12

Finding into death of Richard Mark Ray

49y · Male·Complications of Influenza A infection

…, requiring emergency transfer to hospital. He deteriorated to respiratory failure requiring intubation and ECMO support but died on 29 March. The coroner found custodial and health care management met required standards…

infectious diseasesintensive caredelayparacetamol
SAhospital2020-01-10

Coroner's Finding: FIORETTI Louisa Jill Josephine

19y · Female·2,4-dinitrophenol toxicity

…tient Treatment Order in place. Despite expert multidisciplinary management including sedation, intubation, ECMO, attempted dialysis, charcoal administration, and dantrolene use, she deteriorated rapidly with uncontrolla…

toxicologyemergency medicine2,4-dinitrophenol
SAhospital2020-06-18

Coroner's Finding: THOMPSON Wayne Robert McInnes

33y · Male·Multi-organ failure due to sepsis on a background of severe ischaemic cardiomyop…

…nted to hospital on 30 November 2016 severely septic with cellulitis, requiring intensive support including ECMO and mechanical ventilation. Despite maximal medical therapy, he died three days later. The coroner found no…

cardiologyintensive carewarfarin
QLDhospital2022-07-08

R - Non-inquest findings

0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…

A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…

anaesthesiaintensive carediagnosticproceduralpropofol
VIChospital2018-03-29

Finding into death of Roy Irvin Dorner

64y · Male·Complications of redo thoracotomy/aortic valve replacement in a man with ischaem…

… incised despite use of an oscillating saw and careful technique. The patient required massive transfusion, ECMO support, and extended surgery but developed multi-organ failure and died 29 days post-operatively. The coro…

cardiothoracic surgerycardiology
VIChospital2018-08-31

Finding into death of David William Lobb

53y · Male·Complications of burns sustained in a blast

…complications including severe burns, hypocalcaemia, acidosis, and fungal infection requiring ICU care with ECMO. This death was preventable through proper maintenance, accurate labelling of refrigeration systems, and en…

intensive caretrauma surgeryproceduralsystem
NSWhospital2021-04-16

Inquest into the death of Kelvin MOULDS

61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a c…

Kelvin Moulds, a 61-year-old man, died of hypoxic encephalopathy following a cardiac arrest caused by self-removal of a central venous catheter (CVC) on day 14 post-bilateral lung transplant. The CVC was still in situ de…

cardiothoracic surgerytransplant medicinecommunicationsystemoxycodone
VIChospital2024-12-02

Finding into death of Baby Patel

0y · Unknown·unascertained

…ly with antibiotics, fluids, and retrieval but deteriorated despite intensive care including intubation and ECMO support. Cause of death was unascertained at autopsy. Key preventable failures included: inadequate triage …

neonatologypaediatricsdiagnosticcommunicationcefotaxime
QLDcommunity2020-09-07

C - Non-inquest findings

6y · Male·Sepsis due to melioidosis

… to a regional hospital and then to a tertiary paediatric ICU, but despite maximal intensive care including ECMO, he developed septic shock, pneumonia, ARDS, multiorgan failure, and ultimately brain death. Key learning p…

paediatricsinfectious diseasesdiagnosticcommunicationparacetamol
VIChospital2022-12-16

Finding into death of Arthur Peter Andrianakis

51y · Male·Hyperthermia of unknown cause in a man with cardiac hypertrophy; chronic obstruc…

Arthur Andrianakis, 51, died from hyperthermia of unknown cause with cardiac hypertrophy and COPD. He presented to hospital with respiratory distress following police custody for assaulting his mother. Initial diagnosis …

emergency medicineintensive caresalbutamol
VICcommunity2026-03-04

Finding into death of Anthony Laurence Parisi

39y · Male·Multidrug toxicity (GHB, methylamphetamine, ketamine) in a setting of restraint …

Anthony Parisi, 39, died from multidrug toxicity (GHB, methamphetamine, ketamine) in a setting of police restraint and moderate coronary artery atherosclerosis. He consumed large quantities of GHB and methamphetamine on …

emergency medicineintensive caregamma-hydroxybutyrate
VIChospital2019-02-05

Finding into death of Eliza Gill

18y · Female·Colchicine toxicity

An 18-year-old female died from colchicine toxicity after intentional overdose of her father's medications during a mental health crisis. She ingested approximately 10-15g of colchicine (dose 0.25mg/kg), below the guidel…

emergency medicineintensive carediagnosticsystemcolchicine
QLDhospital2018-10-24

Statis, Joshua Ryan

12y · Male·Cardiac haemorrhage due to or as a consequence of congenital aortic stenosis (su…

Joshua Statis, a 12-year-old with complex congenital aortic stenosis, died 18 days after a redo Konno procedure and aortic valve replacement when a CardioCel patch to the right ventricular outflow tract (RVOT) ruptured, …

cardiothoracic surgerycardiologycommunicationdiagnosticwarfarin
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
NSWhospital2015-11-16

Inquest into the death of Ivy Dwyer

18y · Female·Severe cardiogenic shock caused by myocarditis as a consequence of an unknown vi…

…vealed the enlarged heart. Expert evidence suggests earlier imaging might have enabled earlier transfer for ECMO or transplant consideration, though survival prospects were poor given extent of myocardial damage at autop…

general practiceemergency medicinediagnosticcommunicationloperamide
VIChospital2012-09-26

Finding into death of Holly Bridget Marion South

0y · Female·Hypoxic-ischaemic encephalopathy arising from thrombosis in Blalock-Taussig shun…

Holly South, an 8-month-old with complex congenital heart disease requiring a Blalock-Taussig shunt, died of hypoxic-ischaemic encephalopathy from thrombosis in her shunt after presenting to hospital with vomiting and si…

cardiologycardiothoracic surgerycommunicationsystem
ACThospital2024-12-06

Inquest Into The Death Of Rozalia Spadafora

5y · Female·myocarditis

…nagement including fluid restriction and timely NETS transfer might have provided a chance of survival with ECMO support in Sydney.

emergency medicinepaediatricsdiagnosticcommunication
VIChospital2024-09-26

Finding into death of FH C

11y · Male·Sepsis

An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…

emergency medicinepaediatricsdiagnosticcommunicationrisperidone
VIChospital2025-04-03

Finding into death of Alan John Trevor Deem

67y · Male·Intracranial haemorrhage complicating coronary artery bypass graft surgery follo…

A 67-year-old man died from intracranial haemorrhage following coronary artery bypass graft surgery. He had suffered a right coronary artery dissection during percutaneous coronary intervention at Sunshine Hospital and w…

cardiologycardiothoracic surgerycommunicationsystemdual anti-platelet agents

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