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WA2015-06-22

Inquest into the Death of Shane John ROBINSON

29y · Male·Multiple drug toxicity

Shane John Robinson, a 29-year-old prisoner with complex medical conditions including Crohn's disease, pulmonary embolism, anaemia and schizoaffective disorder, died from multiple drug toxicity in prison. He had been pre…

gastroenterologycardiologysystemmethadone
VIChome2021-06-29

Finding into death of HM

15y · Male·Gastric perforation with early peritonitis; Acute gastric distension and chronic…

HM, a 15-year-old boy with suspected autism spectrum disorder and depression, died from spontaneous gastric perforation with early peritonitis secondary to acute gastric distension.…

paediatricspsychiatrysystemdelaylovan
VIChome2022-04-07

Finding into death of Mr B

75y · Male·Effects of fire

Mr B, aged 75, killed his wife Mrs A by striking her to the head and asphyxiating her with a ligature, then set their house on fire resulting in his own death. Evidence indicates Mr B was experiencing undiagnosed mental …

general practicegastroenterology
VIChospital2026-02-24

Finding into death of Julie Anne White

59y · Female·Complications of a pseudo-obstruction on a background of previous anterior resec…

…following previous sigmoid volvulus resection. She had intellectual disability, dementia, schizophrenia, depression, and chronic bowel dysmotility. Admitted July 2024 with abdominal distension, she underwent flexible sig…

general surgerypalliative care
VICmental health2015-09-24

Finding into death of Elaine Elizabeth Sykes

58y · Female·Multiple injuries sustained in collision with train (pedestrian)

Elaine Sykes, aged 58, was admitted to Dandenong Hospital with acute renal failure and severe mental health deterioration. After 47 days at Acacia Mental Health Unit, she demonstrated substantial improvement and was disc…

psychiatrygeneral medicinesystemcommunication
VIChospital

Finding into death of Mr C

55y · Male·Ascending cholangitis due to choledocholithiasis

…thiasis following recurrent biliary sepsis. He had multiple comorbidities including Alzheimer's disease, depression, and cardiac dysfunction, and was a specialist disability accommodation resident. He was admitted to ICU…

intensive caregeneral medicineantibiotics
VIChospital2022-09-07

Finding into death of Mr AB

17y · Male·Hypoxic ischaemic encephalopathy due to hanging

…tient care. He had complex medical needs including chronic back pain, spinal fusion, post-viral fatigue, depression, anxiety, and gender dysphoria. Critical clinical lessons include: (1) recognition that suicide can be i…

psychiatryemergency medicinesystemcommunicationquetiapine
WAhospital2016-10-24

Inquest into the Death of David WAYMOUTH

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

…th 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. He underwent successful total hip repla…

orthopaedic surgerygeneral surgerymethadone
VIChospital2023-05-23

Finding into death of Silin Wang

25y · Female·multiple injuries

A 25-year-old woman with newly diagnosed metastatic gastro-oesophageal cancer and depression died by suicide on hospital grounds. She was admitted on 30 January 2021 after imaging showed cancer pro…

oncologypsychiatrycommunicationsystemdiazepam
WAhome2014-05-15

Inquest into the Death of Helen Barbara MINETT

55y · Female·Multiple drug toxicity in a woman with coronary artery atherosclerosis

A 55-year-old woman with complex medical history including chronic pain, previous multiple abdominal surgeries, gastrointestinal disorders, mental health issues including DID, and suicidal ideation died from multiple dru…

general practicepain medicinediagnosticcommunicationmorphine hydrochloride
VIChospital2023-05-02

Finding into death of Mr C

56y · Male·Complications of clostridium difficile and malnutrition in the setting of cerebr…

Mr C was a 56-year-old man with cerebral palsy and acquired brain injury who died from complications of Clostridioides difficile infection and malnutrition. He was admitted to hospital on 21 January 2022 with diarrhoea, …

general medicinegastroenterologydelayvancomycin
VIC2024-11-08

Finding into death of Valerie Caithness

54y · Female·Aspiration pneumonia

Valerie Caithness, a 54-year-old with cerebral palsy and intellectual disability residing in specialist disability accommodation, died from aspiration pneumonia following an aspiration event during a colonoscopy performe…

gastroenterologyintensive care
SAhospital2008-06-06

Coroner's Finding: AUSTIN Grant Aaron

29y · Male·aspiration pneumonia complicating acute and chronic Wernicke's encephalopathy an…

…with prolonged refusal to eat and drink from December 2004, initially attributed to psychiatric illness (depression/catatonia) rather than organic causes. An endoscopy showed Helicobacter pylori infection but this findin…

general medicinepsychiatrycommunicationdiagnostictrimethoprim
VIChospital2011-11-29

Finding into death of Ralph James McCracken

65y · Male·complications of end stage chronic obstructive pulmonary disease

Ralph James McCracken, aged 65, died from complications of end-stage COPD following a complex hospital admission. He presented with acute limb ischaemia requiring femoral embolectomy, subsequently developed compartment s…

vascular surgerycolorectal surgeryantibiotics
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 gene deficiency (present in ~0.3% of population) that…

gastroenterologyintensive carediagnosticsystem6-mercaptopurine
QLDhome2005

Shaw, Lillian Margaret

67y · Female·perforated gastric ulcer; morphine toxicity also made a significant contribution

Mrs Lillian Shaw, a 67-year-old obese woman with a history of NSAID use, presented with vomiting and abdominal pain over 36 hours. A GP visited three times without performing adequate physical examination, failed to insp…

general practicegastroenterologydiagnosticmedicationtramadol
VIChospital2016-10-25

Finding into death of Gladys Yvonne Melhuish

69y · Female·Complications of a probable bowel malignancy

A 69-year-old woman with schizophrenia, intellectual disability, and multiple comorbidities died from complications of probable bowel malignancy. In October 2014, regional lymphadenopathy and bowel thickening were identi…

oncologypalliative caremorphine
SAhospital2022-04-13

Coroner's Finding: Cook, Courtney Liza

20y · Female·multi-organ failure due to polypharmacy overdose

A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdos…

emergency medicinegastroenterologydiagnosticcommunicationparacetamol
VIChospital2024-11-13

Finding into death of Angela Bella Kettyle

53y · Female·Aspiration pneumonia complicating large bowel obstruction due to faecal impactio…

Angela Kettyle, a 53-year-old NDIS participant with significant comorbidities including Type II diabetes, cirrhosis, and chronic constipation, died from aspiration pneumonia complicating large bowel obstruction due to fa…

gastroenterologygeneral medicinemorphine
QLDhospital2009-12-03

Heywood, John Martin

68y · Male·Abnormal heart rhythm (arrhythmia) precipitated by coronary atherosclerosis and …

John Martin Heywood, a 68-year-old prisoner, died of natural causes (arrhythmia precipitated by coronary atherosclerosis and phaeochromocytoma) while in custody at the Princess Alexandra Hospital Secure Unit. He had been…

cardiologyendocrinology

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