Coronial
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SAhospital2016-08-04

Coroner's Finding: CAILES Kevin Arnold

53y · Male·sepsis due to spontaneous bacterial peritonitis on a background of end stage liv…

Kevin Arnold Cailes, 53, died from sepsis due to spontaneous bacterial peritonitis on a background of end-stage liver failure. He had cirrhosis diag…

hepatologyinfectious diseasesdiuretics
VIChospital2025-08-19

Finding into death of Con Koumis

43y · Male·complications of decompensated liver failure due to occult sepsis and retroperit…

…ia major requiring regular blood transfusions, died from decompensated liver failure complicated by occult sepsis and retroperitoneal haemorrhage. He was remanded in custody at the time. Con had refused earlier transfusi…

haematologyhepatology
VIChospital2024-12-09

Finding into death of Debra Louise Goold

61y · Female·Decompensated liver failure - Child's Pugh B cirrhosis secondary to renal failur…

…enal failure. She was admitted to Ballarat Base Hospital on 6 September 2023 with liver failure, developed sepsis and multi-organ failure, and commenced end-of-life care on 10 September 2023. The coroner found no evidenc…

hepatologygeneral medicine
SAhospital2015-07-17

Coroner's Finding: SPIERO Marcel Edward

53y · Male·Sepsis from infected ascites (E. coli) in a man with cirrhosis of the liver, hep…

A 53-year-old male prisoner died of sepsis from E. coli-infected ascites complicated by cirrhosis, hepatocellular carcinoma, and diffuse B-cell lymph…

infectious diseaseshepatologymorphine
WAhospital2022-02-14

Inquest into the Death of Jeffrey Lee STRETTLES

52y · Male·complications in association with advanced malignancy (hepatocellular carcinoma)…

…isoner, died from complications of advanced hepatocellular carcinoma, end-stage cirrhosis, and generalised sepsis. He had contracted Hepatitis C in the late 1980s and was diagnosed with liver cancer in early 2017, treate…

gastroenterologyoncologysystemledipasvir
QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

…8 February when he became tachycardic and hypoxic, requiring medical review and antibiotics initiation per sepsis pathway. This review did not occur, causing approximately 3-hour delay in antibiotic administration. Trans…

emergency medicineinfectious diseasesdiagnosticdelayantacid
WAprison- 31 January 2014

Inquest into the Death of Amy TINKER

33y · Female·multiple organ failure complicating sepsis in a woman with cirrhosis of the live…

…y Tinker, a 33-year-old Aboriginal woman with unrecognised cirrhosis from chronic alcohol abuse, died from sepsis-related multi-organ failure while imprisoned. She had been admitted to Royal Perth Hospital in 2004 with d…

general practicehepatologycommunicationsystem
WAhospital2017-09-29

Inquest into the Death of Jared Charles OLSEN

41y · Male·Fulminant sepsis (Klebsiella pneumoniae) with multi-organ failure complicating s…

…full blood count monitoring was not arranged effectively. The patient developed fatal bone marrow aplasia, sepsis and multi-organ failure. Key failures included: absence of written 6-MP prescribing policy; electronic tes…

gastroenterologyintensive carediagnosticsystem6-mercaptopurine
SA2021-11-25

Coroner's Finding: Hancott, Duncan John

56y · Male·urosepsis

Duncan John Hancott, aged 56, died in Mount Gambier Prison from urosepsis secondary to urinary tract infection caused by E. coli. He had significant comorbidities including hepatic…

infectious diseaseshepatologydiagnosticamitriptyline
WAhospital2020-10-08

Inquest into the Death of Wayne Frederick LEESE

54y · Male·Complications including hepatic encephalopathy, pneumonia and multi-organ failur…

Wayne Frederick Leese, a 54-year-old prisoner, died from complications of hepatitis C and hepatocellular carcinoma including hepatic encephalopathy, pneumonia and multi-organ failure. He collapsed at Acacia Prison on 4 M…

hepatologyemergency medicinemethadone
WAhospital2023-04-17

Inquest into the Death of Edward Ivan AFRICH

64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …

Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic l…

respiratory medicinecardiologycommunicationsystemthiamine
VIChospital2013-05-07

Finding into death of Karen Elizabeth Wilkinson

44y · Female·Lymphocytic choriomeningitis virus (LCMV)-like virus infection following failed …

A 44-year-old woman died on 1 January 2007, six days after receiving a cadaveric renal transplant. She was one of three organ recipients from the same donor who died within six days of each other from a novel lymphocytic…

transplant medicinenephrologycommunicationsystem
QLDhospital2024-12-16

Inquest into the death of Shane Anthony May

61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…

Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory…

emergency medicinerespiratory medicineamlodipine
TAShome2022-05-27

Coroner's Finding: TS de-identified

47y · Female·Traumatic closed head injury likely sustained in a fall from standing

TS, a 47-year-old woman with a 18-year history of anorexia nervosa, bulimia, and severe alcoholism, died from a traumatic closed head injury sustained in a fall from standing. At autopsy, blood alcohol concentration was …

emergency medicinegeneral practicecommunicationsystemalcohol
VIChospital2013

Finding into death of Noela McGowan

66y · Female·Complications following paracetamol overdose

A 66-year-old woman died from complications of paracetamol overdose after ingesting Mersyndol (codeine/paracetamol combination tablets). She had developed dependence on over-the-counter Mersyndol over approximately 8 yea…

emergency medicineintensive caresystemmersyndol daystrength
VIChospital2023-08-14

Finding into death of Md Fakrul Alam Sozon

33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …

A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Phy…

gastroenterologyintensive careproceduraldiagnostic

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