Coronial
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SAhospital2019-11-30

Coroner's Finding: FRANKLIN Allen Henry

83y · Male·aspiration pneumonia and delirium complicating surgery for left total knee repla…

…aesthesia, as advised by geriatrician. Despite optimal anaesthetic technique, he developed post-operative delirium with agitation and aggression, requiring a Mental Health Act inpatient treatment order. He subsequently d…

orthopaedic surgerygeriatric medicine
TASaged care2025-01-14

Coroner's Finding: Rickard-Simms, Adrienne Rosemary

75y · Female·postoperative delirium/exacerbation of community acquired pneumonia following le…

…asures. She sustained a neck of femur fracture requiring hemiarthroplasty. Postoperatively, she developed delirium, sepsis, and community-acquired pneumonia, leading to her death. The coroner found the facility had appro…

geriatric medicineorthopaedic surgery
SAhospital2022-12-16

Coroner's Finding: Roocroft, Bryan

84y · Male·acute aspiration complicating periprosthetic fractured right femur (operated) on…

…ent surgical repair on 25 December and was placed on a Level 1 Mental Health Act order for post-operative delirium. On 29 December, he aspirated vomit, became hypoxic, and died. The coroner found care was appropriate thr…

geriatric medicineorthopaedic surgeryoxazepam
QLDaged care2026-02-17

Non-inquest findings into the death of Mr G

84y · Male·Complications of fracture left humerus neck due to fall due to hyperactive delir…

…ith Alzheimer's disease and dementia-related behaviours developed a urinary tract infection causing acute delirium, atrial fibrillation, and multiple falls. After presenting to the emergency department with three falls a…

geriatric medicineemergency medicinediagnosticcommunicationdonepezil
SAhospital2020-07-16

Coroner's Finding: HANAN Desmond George

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

…l with right femoral neck fracture. He was placed on a Mental Health Act Inpatient Treatment Order due to delirium and agitation. He underwent femur repair surgery on day 2 of admission. Hospital-acquired pneumonia devel…

orthopaedic surgerypsychiatryantibiotics
SAhospital2020-06-18

Coroner's Finding: WILKS Deslandes

79y · Male·Pneumonia complicating ischaemic heart disease and dementia

…me with aggressive behaviour, skin lesions, and respiratory symptoms. During hospitalisation he developed delirium in the context of respiratory infection, experienced a fall, and had declining swallow function with aspi…

geriatric medicinepsychiatryrisperidone
SAaged care2024-05-22

Coroner's Finding: Feldstein, Victoria

87y · Female·General inanition complicating mixed vascular and Alzheimer's dementia on a back…

…gust 2020, initially managed conservatively, then surgically repaired on 2 September 2020. Post-operative delirium and pain management led to reduced oral intake. Despite family concerns and medical review, her condition…

geriatric medicineorthopaedic surgery
TASaged care2025-12-12

Coroner's Finding: Mitchelmore, Susan

70y · Female·pneumonia and post-surgical course following repair of neck of femur fracture, i…

…strategies in place. Following surgical fixation at hospital, her postoperative course was complicated by delirium, reduced oral intake, and respiratory compromise, leading to pneumonia. She transitioned to end-of-life c…

geriatric medicinepsychiatryolanzapine
VIChospital2020-05-05

Finding into death of John Hayle

76y · Male·Bronchopneumonia in a man with ischaemic heart disease and treated spinal crush …

… weeks, he developed progressive bilateral lower limb weakness, but recognition was delayed due to severe delirium which complicated neurological assessment. Staff at Frankston Hospital failed to recognise that his neuro…

neurosurgerygeriatric medicinediagnosticcommunicationmk8931
SAhospital2020-07-02

Coroner's Finding: SWINGLER Yvonne Mary

86y · Female·multi-organ failure due to sepsis

An 86-year-old woman with dementia, recent stroke, and multiple comorbidities was admitted with acute delirium and paranoia, subsequently placed on an Inpatient Treatment Order. She developed sepsis secondary to stap…

psychiatryemergency medicinemorphine
VICaged care2021-08-12

Finding into death of Valerie Lucy Jones

86y · Female·Plastic bag asphyxia

An 86-year-old woman with delirium, depression, and multiple cardiac comorbidities died by asphyxiation with a plastic bag while in a transi…

general medicinegeriatric medicinecommunicationsystemmirtazapine
SAhospital2020-06-18

Coroner's Finding: BOES Johannes Josephus

92y · Male·pulmonary thromboembolic disease on a background of infective exacerbation of ch…

…ble factors were identified. The case demonstrates challenges in managing elderly patients with dementia, delirium, and multiple comorbidities during acute illness.

respiratory medicineemergency medicinehaloperidol
SAhospital2017-04-19

Coroner's Finding: O'REILLY Raymond John

91y · Male·pneumonia on a background of chronic congestive cardiac failure and chronic obst…

…OPD and atrial fibrillation presented with confusion, agitation and dyspnoea. Admitted with pneumonia and delirium, he exhibited combative behaviour and resisted oxygen therapy despite dangerously low saturations. A Leve…

geriatric medicineemergency medicineolanzapine
NSWhospital2025-05-28

Inquest into the Death of Garry Small

71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …

…deviated from the Sepsis Pathway with inadequate repeat observations and lactate monitoring. He developed delirium (multifactorial: sepsis, medications including oxycodone 10mg and diazepam, frailty) and fell unwitnessed…

emergency medicinegeriatric medicinemedicationdelayceftriaxone
TAShospital2024-10-11

Coroner's Finding: Vieth, Karl Heinz

92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…

… He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, developing delirium and confusion. The EMU is a short-stay facility unsuitable for complex, confused patients requiring prolo…

general medicineemergency medicinesystemdelaymelatonin
VICaged care2025-09-10

Finding into death of IWT

77y · Female·Complications of malnutrition in a woman with paranoid delusions

…sychiatric history died from complications of malnutrition while an inpatient with paranoid delusions and delirium. She was admitted following falls and required compulsory treatment under the Mental Health Act due to re…

psychiatrygeriatric medicineolanzapine
SAhospital2020-01-10

Coroner's Finding: BICKLEY Jon

79y · Male·ischaemic heart disease complicating chronic obstructive airways disease

…disease while subject to an Inpatient Treatment Order at Flinders Medical Centre. He presented with acute delirium and agitation following a fall, requiring significant sedation. A MET call was made on 12 August 2016 whe…

geriatric medicinepsychiatryfentanyl
VIChospital2025-12-15

Finding into death of Yan Jin

64y · Male·Pneumonia secondary to ischaemic cerebrovascular incidents, hypertension, and at…

…DIS care). On day 2 of admission, he experienced acute decline in consciousness (GCS 6-7) with hypoactive delirium, attributed to progression of cerebrovascular disease from previous stroke. He developed respiratory comp…

emergency medicinegeneral medicinepiperacillin/tazobactam
VICaged care2019-02-21

Finding into death of Kathleen Schleibs

88y · Female·Sepsis complicated by multiple organ failure in a woman with comorbidities in th…

…t; failure to perform C-reactive protein testing or urine culture after catheter removal despite signs of delirium; and delayed recognition/escalation of deterioration at the residential facility. The woman experienced u…

orthopaedic surgerygeriatric medicinediagnosticcommunicationfentanyl
SAaged care2024-05-22

Coroner's Finding: Kaczaniw, Iwan

93y · Male·general inanition on a background of cognitive impairment, congestive cardiac fa…

…lity. He was under a guardianship order with special powers. Post-operatively, he developed pneumonia and delirium requiring an inpatient treatment order. After discharge, he had further unwitnessed falls and progressive…

geriatric medicineorthopaedic surgery

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