Coronial
VICaged care2020-11-06

Finding into death of VA

73y · Female·Combined effects of congestive cardiac failure, coronary artery atherosclerosis …

…and cardiomegaly while an inpatient in a psychiatric unit. She had recently been treated for C. difficile colitis requiring ICU admission for hypotension. The coroner found that medical care was appropriate and the deat…

psychiatryintensive caremetaraminol
VIChospital2024-10-10

Finding into death of Makayla Lee Wadeson

9y · Female·Streptococcus pneumoniae and Candida albicans pneumonia and empyema in a girl wi…

Makayla Lee Wadeson, a 9-year-old autistic girl with ulcerative colitis on immunosuppressive therapy, presented to the emergency department with ear infection symptoms on 29 Jul…

emergency medicinepaediatricsdiagnosticsystemcefalexin
TAShospital2021-11-29

Coroner's Finding: Bennett, Anthony George

77y · Male·shock due to bowel ischaemia following massive blood loss due to bleeding of the…

Anthony George Bennett, a 77-year-old man with significant comorbidities including ischaemic heart disease, atrial fibrillation, peripheral vascular disease, and end-stage kidney disease, died from shock due to bowel isc…

vascular surgerycardiology
QLDaged care2025-04-17

Non-inquest findings into the death of Mr H.

89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…

… man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that small bowel m…

geriatric medicinegeneral practicediagnosticcommunicationmacrogol
WAhospital2017-09-29

Inquest into the Death of Jared Charles OLSEN

41y · Male·Fulminant sepsis (Klebsiella pneumoniae) with multi-organ failure complicating s…

A 41-year-old man with newly diagnosed severe Crohn's colitis was prescribed 6-mercaptopurine (6-MP) after only 5 days of hospital treatment. He had a homozygous TPMT …

gastroenterologyintensive carediagnosticsystem6-mercaptopurine
TAS2018-08-27

Coroner's Finding: Horsham, Gordon James

78y · Male·Complete transection of body sustained in single motor vehicle crash

…ealth conditions including chronic kidney disease, diabetes with renal failure, and history of ulcerative colitis. The vehicle was mechanically sound. This death was entirely preventable through adherence to speed limit…

VIChospital2016-08-18

Finding into death of Susan Bourke

49y · Female·Widespread small and large bowel, splenic and hepatic infarction secondary to se…

… to the ED with months of abdominal pain, weight loss and diarrhoea, initially suspected to be ulcerative colitis. A CT scan on 26 August identified splenic infarcts but failed to recognize the critical arterial stenosi…

emergency medicineradiologydiagnosticcommunication
NSW2022-10-12

Inquest into the death of ZH

29y · Male·Hanging

… of father, grandfather and aunt; relationship breakdown; drug addiction; medical comorbidities including colitis; and crucially, realisation that release was 12 months away rather than imminent); (2) failure to detect …

psychiatrygeneral practicecommunicationsystemmethamphetamine
SAhospital2002-05-17

Coroner's Finding: MITTA Wilhelmina

88y · Female·sepsis of unknown origin

… signs, transferred to hospital with sepsis of unknown origin (possibly perforated bowel, diverticulitis, colitis, or ischaemic bowel). Clinical lesson: early recognition of physical illness in elderly patients with dem…

geriatric medicinepsychiatrydiagnosticanti-psychotic medication
VIChospital2016-10-24

Finding into death of Child A

3y · Male·thrombotic microangiopathy

A 3-year-old child died from thrombotic microangiopathy (haemolytic uraemic syndrome) secondary to Shiga toxin-producing E. coli infection, likely acquired from consumption of unpasteurised milk. Early presentation to GP…

paediatricsemergency medicineondansetron
VIChospital2012-10-24

Finding into death of Nicola Spina

63y · Male·End stage ischaemic cardiomyopathy and chronic renal impairment

Nicola Spina, a 63-year-old male prisoner at Port Phillip Prison, died from end-stage ischaemic cardiomyopathy and chronic renal impairment on 17 July 2010. He presented to St Vincent's Hospital on 6 July 2010 with acute…

emergency medicineintensive careoxycodone
WAhospital2016-10-24

Inquest into the Death of David WAYMOUTH

47y · Male·Multi organ failure and sepsis complicating ulcerating colitis and intestinal ob…

David Waymouth, a 47-year-old prisoner with extensive medical comorbidities including hepatitis C, obesity, chronic pain requiring methadone, and depression, fell from his bed in prison and sustained a right hip fracture…

orthopaedic surgerygeneral surgerymethadone
NSWhospital2016-10-26

Inquest into the death of Audrey MacGREGOR

88y · Female·combined effects of an overdose of hydromorphone and complications of pneumonia …

…c lung disease, heart disease, and recent pneumonia following faecal transplant for clostridium difficile colitis was prescribed 0.5 mg hydromorphone subcutaneously for respiratory distress on 24 October 2013. Two nurse…

cardiologyrespiratory medicinemedicationcommunicationhydromorphone
QLDhospital2019-09-05

Mrs MDF - Non-inquest findings

76y · Female·multisystem organ failure due to or as a consequence of ischaemic small intestin…

A 76-year-old woman presented to hospital with abdominal pain and was found on CT scan to have ischaemic colitis with signs of profound shock. The Consultant Surgeon decided on conservative management with fluid resusc…

surgeryintensive carediagnosticcommunicationtramadol
VIChospital2016-08-25

Finding into death of Robert Kingsley Whitehead

84y · Male·Complications of gout and old spinal injury, cause unknown

An 84-year-old male prisoner with multiple comorbidities (gout, spinal cord injury, renal impairment, cardiac failure) presented with chest infection, abdominal pain, and urinary retention. He was treated with intravenou…

haematologyinfectious diseasesmirtazapine
TASaged care2022-08-11

Coroner's Finding: Dora, Bogdan

74y · Male·Aspiration of gastric contents, significantly contributed to by advanced dementi…

Mr Bogdan Dora, aged 74, died from aspiration of gastric contents while residing at Roy Fagan Centre, a residential aged care facility for people with dementia. He had advanced dementia, emphysema, and severe atheroscler…

geriatric medicinepsychiatry
SA2026-04-23

Coroner's Finding: Wilkins, Reginald James

86y · Male·ischaemic and hypertensive heart disease

An 86-year-old man died of ischaemic and hypertensive heart disease while serving a prison sentence. He had multiple comorbidities including atrial fibrillation, congestive cardiac failure, and cirrhosis. The coroner exa…

cardiologygeneral practiceatorvastatin
VIChospital2026-03-12

Finding into death of Nicole Jennifer Kateiva

39y · Female·Respiratory failure in the setting of aspiration pneumonia in a woman with arthr…

Nicole Kateiva, a 39-year-old woman with arthrogryposis multiplex congenita, intellectual impairment, and epilepsy, died from respiratory failure due to aspiration pneumonia. She presented to hospital with two days of co…

general medicineintensive careceftriaxone
VIChospital2019-08-07

Finding into death of Leon Edward Balshaw

55y · Male·Bronchopneumonia in a man with a healing myocardial infarction

Leon Edward Balshaw, aged 55, died from bronchopneumonia complicating a healing myocardial infarction while in police custody. He was arrested on 25 January 2018 following a domestic dispute and taken to Bairnsdale Regio…

emergency medicineintensive care
VIChospital2022

Finding into death of Mr E

67y · Male·Fulminant liver failure

A 67-year-old man presented to his GP with discoloured urine. Blood tests revealed acute liver toxicity but critical results were communicated via facsimile, with unclear timing of GP's review. The patient deteriorated r…

general practiceemergency medicinecommunicationdelayibuprofen

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