Coroner's Finding: Bertram, Kerry Anne

42y · Female·multiorgan failure complicating hyperthermia and metabolic acidosis following suspected ingestion of caustic soda

A 42-year-old woman with long-standing depression, substance use issues, and multiple mental health presentations died from multi-organ failure following ingestion of caustic soda. She was found unresponsive at home on 13 May 2019 and admitted to hospital where she was placed on a Mental Health Act treatment order. Despite appropriate intensive care management including haemodiafiltration, ethanol infusion, and treatment of complications (oesophageal perforation, mediastinitis, acute kidney injury, septic shock), she developed cerebral oedema with herniation and died on 15 May 2019. The coroner found her care was appropriate and attentive. Key clinical lessons include recognising the severity of caustic ingestion, managing toxic metabolic complications, and addressing the underlying mental health crisis that preceded this fatal event.