Coronial

27 results for disease relapse

WAhome2020-07-01

Inquest into the Death of Child SJC (Name Subject to Suppression Order)

2y · Female·Complications relating to metastatic neuroblastoma

…therapy, radiotherapy, and biotherapy at Princess Margaret Hospital. She initially achieved remission but relapsed after 7 months. Dinutuximab immunotherapy, considered standard care, was unavailable due to global suppl…

oncologypaediatric surgerychemotherapy agents
SA2013-02-13

Coroner's Finding: NYLANDER Harry Richard

58y · Male·metastatic multiple myeloma

…as a 2-3 week delay in initial CT scanning in 2004, earlier diagnosis would not have prevented death. The disease was disseminated and advanced at diagnosis. The one-month interval to diagnosis was shorter than communit…

oncologyhaematologydelay
VICmental health2014-02-10

Finding into death of Frank (Francesco) Sette

72y · Male·Cranial fracture and intracranial haemorrhage from self-inflicted fall

… psychiatric ward. He was an involuntary patient in the High Dependency Unit experiencing acute psychotic relapse with command hallucinations. Clinical staff were present and responding appropriately to his acute agitat…

psychiatrygeriatric medicinesodium valproate
WAmental health2023-02-13

Inquest into the Death of Philip SULLEY

58y · Male·coronary artery arteriosclerosis (natural causes)

…t was discharged; his presentation was judged appropriate at the time despite later appearing to be early relapse. He re-presented on 22 April 2020 with florid psychosis and was admitted to BMHU under a Form 6A involunt…

psychiatryemergency medicinecommunicationolanzapine
VIChospital2024-03-19

Finding into death of Craig Ashley Hill

53y · Male·Cardiomegaly in a man with obesity and chronic liver disease

Craig Ashley Hill, a 53-year-old man with multiple comorbidities including obesity, chronic liver disease with cirrhosis, cardiomegaly, hypertension, diabetes, and mental health conditions, died suddenly in hosp…

psychiatrycardiologydiazepam
VIChospital2014-10-01

Finding into death of Raymond John O_Brien

71y · Male·acute myocardial infarction due to coronary artery disease

Raymond O'Brien, a 71-year-old forensic patient with a history of ischaemic heart disease, hypertension, and dyslipidaemia, was admitted to hospital with chest pain in August 2013. Initial diagno…

cardiologypsychiatryaspirin
VIChome2026-05-25

Finding into death of Robyn Julia Richards

69y · Female·Hydrocephalus and subarachnoid haemorrhage in the setting of a fall in a woman w…

…ebruary 2025. The exact cause of hydrocephalus remained unclear—possibly related to trauma, infection, or disease relapse. The coroner found all assessment and treatment to be appropriate, making no adverse findings.

general practiceparamedicine
SAhospital2019-06-12

Coroner's Finding: NGUYEN An Hoang Le

4y · Male·acute lymphoblastic leukaemia

…, leukapheresis, neurosurgical intervention for cerebral bleeding, and stem cell transplant in Sydney, he relapsed in July 2015. Medical care was optimal and appropriately managed. The coroner found no clinical issues c…

haematologyintensive carechemotherapy
VIChospital2024-08-07

Finding into death of Georgios Stamkos

68y · Male·Complications of a witnessed airway obstruction from food bolus in a man with dy…

…e during a supervised hospital meal. He had been admitted with worsening dysphagia, delirium, and bipolar relapse. Speech pathology had prescribed texture-modified diet and nasogastric feeding due to high aspiration ris…

psychiatryspeech pathologyrisperidone
VIChospital2026-05-22

Finding into death of Stratos Ioannidis

45y · Male·focal coronary artery disease and cardiomegaly

Stratos Ioannidis, age 45, died at Maroondah Hospital on 28 March 2025 from focal coronary artery disease and cardiomegaly during an involuntary psychiatric admission. He presented with acute psychosis from bipo…

psychiatryemergency medicinecommunicationsystemolanzapine
NSWhome2017-06-07

Inquest into the death of Craig LEISHMAN

46y · Male·Complications of chronic alcoholism and hypertension

…ber. He collapsed in the shower on 2 November and could not be resuscitated. Autopsy revealed fatty liver disease, enlarged heart, and elevated ketoacid levels consistent with alcoholic ketoacidosis (AKA)—a potentially …

intensive carepathologyalcohol
WAmental health2018-07-16

Inquest into the Death of Stanley KING

45y · Male·Cardiorespiratory arrest due to coronary artery disease, severe psychosis requir…

Stanley King, a 45-year-old man with severe psychosis, coronary artery disease, and obesity, died from cardiorespiratory arrest triggered by antipsychotic-induced laryngeal dystonia. A…

psychiatryemergency medicinediagnosticmedicationzuclopenthixol
VICaged care2024-03-28

Finding into death of Joseph David Jones

76y · Male·Unascertained - natural causes

…an with schizoaffective disorder, was admitted to an acute psychogeriatric unit on 29 November 2022 for a relapse associated with medication non-adherence. He was commenced on intramuscular olanzapine 10mg daily and rev…

psychiatrygeriatric medicineolanzapine
WAhospital2019-09-23

Inquest into the Death of Dylan James RILEY

16y · Male·pulmonary embolism secondary to nephrotic syndrome

…st 2015. He presented to Rockingham Hospital with dyspnoea, hypoxia, tachycardia and hypotension during a disease relapse. Doctors appropriately diagnosed acute pulmonary oedema—a common complication of nephrotic syndro…

nephrologyintensive caredelayenoxaparin
QLD2010-05-19

Jeffrey, Lawrence Edward

63y · Male·Metastatic carcinoma of the lung

…o-face examination, and no chest X-ray was ordered despite persistent respiratory symptoms and antibiotic relapse. While earlier diagnosis would have occurred weeks sooner, the cancer was already advanced beyond effecti…

general practicerespiratory medicinediagnosticdelayfurosemide
SAhospital2020-07-02

Coroner's Finding: WHATLEY Deborah Rose

55y · Female·ischaemic heart disease complicated by epilepsy, asthma and schizophrenia

…ning she was found unresponsive and died despite resuscitation attempts. Autopsy revealed ischaemic heart disease with significant coronary stenosis as the primary cause. The coroner found the hospital care appropriate.…

emergency medicinepsychiatryclozapine
VICaged care2026-01-19

Finding into death of Kevin Thomas Maloney

39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…

… and clear protocols; (3) support plans must be updated promptly following psychiatric hospitalization or relapse; (4) effective handovers between shifts are critical safety measures; (5) medication administration shoul…

psychiatryaddiction medicinecommunicationsystemheroin
VICmental health2023-05-22

Finding into death of Jennifer Gebert

49y · Female·Unascertained; most likely cardiac abnormality

Jennifer Gebert, a 49-year-old with long-standing mental illness and substance use disorder, died unexpectedly in an acute psychiatric unit on 6 December 2019. She presented to the ED intoxicated (BAC 0.159%) following b…

psychiatryemergency medicinealcohol
QLD2019-11-21

Gavenor, Ashley Glenfield

48y · Male·Coronary atherosclerosis and minor trauma

Ashley Glenfield Gavenor, a 48-year-old Indigenous man with coronary artery disease, hypertension, diabetes, and bipolar affective disorder, died in Townsville Correctional Centre following…

cardiologypsychiatryaspirin
NSWhospital2015-08-17

Inquest into the death of Manjit SINGH

33y · Male·hypoxic respiratory failure following right pneumonectomy for treatment of sever…

…nd the vulnerability of migrant workers to exploitation affecting nutrition and TB reactivation risk. His disease relapsed despite initial drug treatment, necessitating surgery. The coroner found malnutrition a contribu…

respiratory medicinecardiothoracic surgerydiagnosticcommunicationtuberculosis medications

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