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
TAShospital2024-09-12

Coroner's Finding: Chapman, Jane Ann

74y · Female·Post-operative exacerbation of delirium and terminal functional deterioration du…

Jane Ann Chapman, 74, presented to hospital with delirium, fever and suspected urinary tract infection. She fell from an Emergency Department trolley bed, sustaini…

emergency medicineorthopaedic surgeryproceduralsystem
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
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
SAhospital2016-09-01

Coroner's Finding: CALLAGHAN Brian Francis

79y · Male·Multi-organ failure due to pneumonia and bleeding duodenal ulcer complicating su…

…cquired pneumonia, upper gastrointestinal bleeding from a duodenal ulcer, acute kidney injury, and severe delirium requiring Mental Health Act detention. Despite appropriate medical management including antibiotics, bloo…

general surgeryorthopaedic surgery
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
TAShospital2025-04-30

Coroner's Finding: Warn, Kenneth

86y · Male·aspiration pneumonia following injuries sustained in a motor vehicle crash and p…

…spital course was complicated by progressive frailty, deconditioning, decreased oral intake, and terminal delirium. He died on 27 May 2024 from aspiration pneumonia. No clinical errors or preventable healthcare failures …

emergency medicineorthopaedic surgery
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
TAShospital2025-01-20

Coroner's Finding: Lowe, Wayne Anthony

58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humeru…

…eft humerus. Clinical lessons: falls risk assessment should occur at admission, not after the first fall. Delirium assessment was inadequate and was a significant contributing factor. A Patient Safety Assistant was unava…

orthopaedic surgerygeneral medicinesystemdelay
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
SAaged care2022-04-14

Coroner's Finding: Lauder, Ian Ross

80y · Male·general inanition and pneumonia on a background of advanced vascular dementia, c…

…or cerebral artery stroke, anaemia requiring blood transfusions, gastrointestinal bleeding, and worsening delirium. Upon discharge, he continued to refuse food and medication, with further falls. Palliative care was comm…

geriatric medicineorthopaedic surgeryproton pump inhibitors
SAhospital2022-08-15

Coroner's Finding: Larchin, John

87y · Male·infective exacerbation of chronic obstructive lung disease

… prior diagnosis of lung disease suffered a hip fracture requiring surgery. Postoperatively, he developed delirium and hypoxia. Two Inpatient Treatment Orders were appropriately made to enable medical treatment including…

orthopaedic surgerypsychiatryhaloperidol
SAhospital2023-04-11

Coroner's Finding: Rerich, Josef

78y · Male·multi-organ failure complicating neck of femur fracture (operated) on a backgrou…

…ged care facility. Post-operatively he deteriorated with acute renal failure, respiratory compromise, and delirium with combative behaviour. A Level 1 Inpatient Treatment Order was imposed to facilitate safe administrati…

orthopaedic surgerygeneral medicinehaloperidol
SAhospital2018-03-29

Coroner's Finding: BUTSON Graham Joseph

81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…

…and atrial fibrillation; a lung mass was suspected but CT imaging could not be completed due to his acute delirium. He was detained under mental health legislation for safety reasons. The coroner found his death was not …

orthopaedic surgerygeneral medicinesystemwarfarin
VIChospital2016-11-10

Finding into death of Beverley Joy Leggett

79y · Female·Pulmonary thromboembolism in the setting of right elective total hip replacement

…, early mobilisation, mechanical foot compression, and hypotensive anaesthesia. Post-operatively, she had delirium and confusion, which may have contributed to reduced mobility despite physiotherapy. Foot compression was…

orthopaedic surgeryanaesthesiasystemaspirin
VIChospital2017-02-17

Finding into death of Christopher Albert Nance

67y · Male·ischaemic heart disease

…al atrial fibrillation underwent arthrotomy for septic arthritis of the knee. He developed post-operative delirium attributed to anaesthesia, analgesics (tramadol), and possible alcohol withdrawal. A seizure-like episode…

cardiologyorthopaedic surgerycommunicationproceduraltramadol

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