Coronial

11 results for diabetic ketoacidosis risk

VIChome2025-07-24

Finding into death of Jill Hughes

75y · Female·Infective complications of a left hand injury with diabetic ketoacidosis

…tions of a left hand wound sustained in a fall from a ladder in November 2023, complicated by undiagnosed diabetic ketoacidosis. Despite family encouragement to seek medical attention, she declined treatment, claiming fa…

infectious diseasesendocrinologydelaydiagnostic
VICcommunity2021-08-16

Finding into death of Phillip John Sealey

62y · Male·Diabetic ketoacidosis in a man with coronary atherosclerosis and cardiomegaly

…hyperglycemia. Phillip deteriorated rapidly at home that evening with altered mental status and died from diabetic ketoacidosis with concurrent coronary atherosclerosis. The coroner found that performing a fingerprick gl…

general practiceemergency medicinediagnosticdelayfentanyl
TAShospital2024-12-17

Coroner's Finding: Brown, Paul Louis

64y · Male·Subdural haematoma with mass effect following thrombolysis for acute myocardial …

…g diabetes, mental illness, chronic alcohol misuse, and previous traumatic brain injury was admitted with diabetic ketoacidosis and acute kidney injury. He developed acute myocardial infarction (STEMI) and received throm…

intensive carecardiologytenecteplase
TAShospital2024-09-12

Coroner's Finding: Chapman, Jane Ann

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

…tment trolley bed, sustaining a neck of femur fracture requiring surgery. Post-operatively, she developed diabetic ketoacidosis and influenza A, requiring ICU admission. She died from post-operative delirium and function…

emergency medicineorthopaedic surgeryproceduralsystem
VICcommunity2023-12-20

Finding into death of Lachlan McMahon Cook

16y · Male·Hypoxic/ischaemic encephalopathy in the context of diabetic ketoacidosis

A 16-year-old with Type 1 Diabetes died from diabetic ketoacidosis (DKA) precipitated by acute gastroenteritis acquired while on a school trip to Vietnam. Desp…

endocrinologygeneral practicediagnosticcommunicationinsulin
TAShome2024-10-23

Coroner's Finding: Earl, Kathleen May

58y · Female·Complications of poorly controlled type 2 diabetes

…nisation; and failure to maintain regular attendance at diabetes clinic. Her GP correctly identified poor diabetic control on 10 March and 6 June 2022 but did not re-refer to specialist clinic or escalate care. IHCS term…

general practiceendocrinologysystemcommunicationryzodeg
VICmental health2022-06-29

Finding into death of Melissa Gaultier

34y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian), in circums…

…tcomings: failure to observe Melissa for adequate time, disregarding Monash Health's advice, lack of proper risk assessment before leave, and inadequate documentation. The coroner found the death preventable had proper r…

psychiatryobstetricscommunicationdiagnostic
VIChospital2025-10-28

Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …

…onal Centre when his condition deteriorated. Critical clinical lessons include: (1) patients with chronic diabetic ulcers refusing treatment require enhanced vigilance and structured monitoring; (2) wound care management…

infectious diseasesvascular surgerydiagnosticsystemantibiotics
VIChome2021

Finding into death of Tate Hobbs

36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)

…on. The concurrent prescription of multiple central nervous system depressants created substantial overdose risk. Dr S.'s prescribing was unsafe due to inadequate monitoring, coordination failure with specialists, and fa…

general practicepain medicinemedicationcommunicationpregabalin
NSWhospital2025-05-28

Inquest into the Death of Garry Small

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

A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…

emergency medicinegeriatric medicinemedicationdelayceftriaxone
QLDhospital2024-07-30

PATELESIO, Etevise

29y · Female·Hypoxic-ischaemic encephalopathy due to cardiac arrest of undetermined cause

…have enabled earlier intervention. Key clinical lessons: ensure post-sedation monitoring compliance in high-risk patients; implement continuous monitoring including pulse oximetry, ECG, and end-tidal CO2; clarify conflic…

emergency medicineintensive caremonitoringsystemdroperidol

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