Coronial
WAhospital2017-03-31

Inquest into the Death of John HOUGHTON

72y · Male·Metastatic bladder cancer; likely mechanism pulmonary embolism from combined eff…

…gularities suspicious for cancer, urologist Dr S. did not consider cancer likely and arranged a flexible cystoscopy to exclude this diagnosis. However, no cystoscopy date was obtained before the hip replacement on 23 Jun…

urologyorthopaedic surgerydiagnosticdelaynitrofurantoin
SA2009-06-03

Coroner's Finding: GROOTVELD Gerard

75y · Male·disseminated carcinoma of the prostate gland

…red to hospital in October 2006 and hospice in December, receiving appropriate palliative care including cystoscopy for bladder bleeding and radiotherapy. The coroner found medical treatment at all settings was satisfact…

palliative carecorrectional health
TAShospital2017-06-19

Coroner's Finding: Nancarrow, Maurice Cecil

76y · Male·multiple organ failure due to large volume aspiration of gastric contents during…

…ed from multiple organ failure following aspiration of gastric contents during anaesthetic induction for cystoscopy on 15 August 2015. He had undergone colorectal surgery on 30 July with complications including splenic i…

general surgeryurologydiagnosticcommunicationdiuretics
NSWhospital2020-02-25

Inquest into the death of Kerry Curtis

78y · Male·multi-lobar pneumonia and pleural effusions on a background of urothelial carcin…

Kerry Curtis, a 78-year-old prisoner with multiple chronic conditions including COPD, bladder cancer, and cardiac disease, died of multi-lobar pneumonia and pleural effusions following chemotherapy for invasive bladder c…

oncologygeriatric medicine
NThospital2003-07-17

Inquest into the death of Lennie Pinawrut

67y · Male·acute renal failure with associated severe acidosis and hyperkalemia

…old Aboriginal male with dementia was discharged from Royal Darwin Hospital on 4 November 2001 following cystoscopy and bladder neck incision for suspected obstruction. Critical communication failures meant the treating …

urologysurgerycommunicationdelaygentamicine
NSW2021-10-12

Inquest into the death of Donald GREENAWAY

88y · Male·Metastatic prostate carcinoma

Donald Victor Greenaway, an 88-year-old man serving a 21-year prison sentence, died from metastatic prostate carcinoma in the Aged Care Ward at Long Bay Correctional Centre. He had been diagnosed with stage IV prostate c…

oncologyradiation oncologyandrogen deprivation therapy
WA2025-06-12

Inquest into the Death of Graham John BUTLER

76y · Male·out-of-hospital cardiac arrest in a man with coronary artery atherosclerosis and…

Graham John Butler, aged 76, was a sentenced prisoner at Acacia Prison who died from out-of-hospital cardiac arrest caused by coronary artery atherosclerosis in the context of long-standing type 2 diabetes, hypertension,…

correctional healthgeneral medicinebenzydamine
WAhospital2014-12-30

Inquest into the Death of Gheorghe Gruici

71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…

Gheorghe Gruici, a 71-year-old life-sentenced prisoner, died of organ failure from chronic renal failure, infective endocarditis, and chest infection. Over 15 years in custody, he developed multiple comorbidities includi…

general medicinenephrologyomeprazole
WAhospital2004-06-17

Inquest into the Death of Edmiston

41y · Female·Peritonitis following surgical procedure to the urinary bladder, due to infected…

…dmiston, a healthy 41-year-old woman, died of peritonitis and sepsis following minor bladder procedures (cystoscopy, hydrodilatation, and biopsy) at Joondalup Health Campus on 14 February 2003. The biopsies were performe…

urologygeneral surgerydiagnosticmedicationamoxicillin
WAhospital2022-10-05

Inquest into the Death of David Arthur RICE

75y · Male·acute bronchopneumonia in a man with comorbidities

A 75-year-old sentenced prisoner died from acute bronchopneumonia with comorbidities. Mr Rice had extensive medical complexity including COPD, cardiac disease, peripheral vascular disease, and diabetes. He was appropriat…

general medicinecardiologysystemapixaban
WAhospital2015-08-28

Inquest into the Death of Constantinas PAPAKOSTAS

66y · Male·carcinomatosis complicated by recurrent sepsis and multisystem failure in a man …

A 66-year-old man with renal cell carcinoma died in hospital from carcinomatosis with sepsis and multisystem failure. Critical clinical lesson: haematuria in 2005 was not adequately investigated with imaging despite recu…

urologyoncologydiagnosticdelay
WAhospital2023-03-30

Inquest into the Death of Hugh WARD

89y · Male·Complications of cerebrovascular accident (stroke); specifically a catastrophic …

Hugh Ward, an 89-year-old sentenced prisoner, died from complications of stroke following an embolic cerebrovascular accident at Sir Charles Gairdner Hospital. While incarcerated, Mr Ward had multiple comorbidities inclu…

neurologycardiologycommunicationsystemwarfarin
SAhospital2009-07-30

Coroner's Finding: BRUNT Sidney

65y · Male·acute right subdural haematoma

Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…

general practiceemergency medicinemedicationcommunicationwarfarin
WAhospital2023-10-18

Inquest into the Death of Corazon Contreras KEELEY

71y · Female·complications of metastatic endometrial carcinoma, treated palliatively

Corazon Contreras Keeley, a 71-year-old woman with postmenopausal bleeding, was investigated for possible endometrial cancer. Dr K. performed a hysteroscopy with dilation and curettage (HDC) on 29 November 2019, observin…

gynaecologyoncologydiagnosticcommunication
QLDhospital2024-11-20

Non-inquest findings into the death of Mr W

82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis

An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …

general medicinegeriatric medicinediagnosticcommunicationendone 2.5mg

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