Coronial
SAaged care2007-06-28

Coroner's Finding: BLAKE Elizabeth Mathilda

76y · Female·lower limb ischaemia due to diabetes and peripheral vascular disease

…gressing to dementia, diabetes, and peripheral vascular disease with progressive lower limb necrosis and ulceration. During her final three months, her medical condition declined markedly. She received appropriate ongoin…

geriatric medicinepsychiatrymorphine
VICmental health2025-11-11

Finding into death of Graziano Birgi

86y · Male·Oesophageal perforation

…al perforation with pleural effusion, likely secondary to underlying disease such as malignancy, chronic ulceration, or inflammation. The death was determined to be from natural causes. Clinical lessons include the impor…

psychiatrygeriatric medicine
WAhospital2005-03

Inquest into the Death of Bert Sharpe

58y · Male·Gastrointestinal haemorrhage due to erosive gastritis

Bert Sharpe, aged 58, died from gastrointestinal haemorrhage due to erosive gastritis at Sir Charles Gairdner Hospital on 19 April 2004. He had been an involuntary psychiatric patient at Graylands Hospital since 1992, fo…

psychiatrygeneral surgery
TAScommunity2024-01-30

Coroner's Finding: Ryan, Robert John

35y · Male·Multiple organ failure—cause not determined to requisite standard

…ng failed to detect farm chemicals in blood samples; autopsy revealed multiorgan failure and oesophageal ulceration but no primary pathology. The coroner found the cause of death could not be determined to the requisite …

toxicologyintensive carediagnosticdelayparoxetine
NSWhome2010-08-26

Coroner's Finding: Kate Therese Bugmy

26y · Female·Streptococcal Sepsis resulting from Skin Ulceration and complications of Cerebra…

Kate Therese Bugmy, a 26-year-old woman with cerebral palsy, epilepsy, and intellectual disability, died on 28 June 2007 of Streptococcal sepsis from infected pressure ulcers. She was cared for at home by her mother Daph…

general medicineemergency medicinesystemcommunication
SAaged care2016-08-22

Coroner's Finding: SCHULZ Bertha Anna

89y · Female·Multiple organ failure with cachexia on a background of chronic lower limb ulcer…

An 89-year-old woman with chronic venous leg ulcers complicated by squamous cell carcinoma died of multiple organ failure in a nursing home. She had been under guardianship following hospitalization in January 2013 for d…

geriatric medicinegeneral medicine
NSW2026-05-20

Inquest into the death of Mr Edward Curic aka Grahovac

49y · Male·Diabetes Mellitus and the Consequences thereof

Mr Edward Curic (49) died at Long Bay Correctional Complex on 21 May 2022 from diabetes mellitus and complications. He had poorly controlled Type 2 diabetes for 30 years with severe complications including bilateral ampu…

correctional healthgeneral medicinemethadone
SAhospital2015-08-27

Coroner's Finding: O'LEARY Judith Beverley

75y · Female·exacerbation of end-stage chronic obstructive pulmonary disease

Judith Beverley O'Leary, 75-year-old woman with end-stage COPD, dementia, depression and multiple comorbidities, died from exacerbation of COPD with secondary respiratory tract infection. She was placed under guardianshi…

respiratory medicineemergency medicinequetiapine
SAhospital2015-08-27

Coroner's Finding: JONES John David

65y · Male·Multi-organ failure in a man with an ischaemic right leg treated with opioids

A 65-year-old man with multiple chronic conditions (COPD, cardiac failure, diabetes, obesity) was admitted with pneumonia and severe ischaemic right leg pain. Opioid analgesia for the leg pain precipitated delirium, requ…

emergency medicinerespiratory medicineopioids
VIChome2021-10-28

Finding into death of Yunjie Zhang

20y · Female·Complications of malnutrition in the setting of presumed nitrous oxide use

A 20-year-old university student living alone in Melbourne died between 28 July and 7 August 2020 from complications of malnutrition in the setting of presumed nitrous oxide use. Thousands of nitrous oxide canisters were…

forensic medicinepublic healthsystemnitrous oxide
TAShospital2023-02-17

Coroner's Finding: Hanslow, Rodney James

86y · Male·progressive cognitive decline/decompensation and gastrointestinal haemorrhage

…ical errors occurred: (1) his proton pump inhibitor (PPI), which he had taken for 14 years to prevent GI ulceration, was discontinued on admission and only given once on 22 July; (2) nursing staff failed to adequately co…

general medicinegastroenterologymedicationdiagnosticproton pump inhibitor
NSWaged care2019-09-27

Inquest into the death of Sylvia CONFOS

87y · Female·Natural causes in the context of multiple co-morbidities including a sacral ulce…

87-year-old woman died in aged care with a stage 4 sacral ulcer and multiple comorbidities. Key clinical lessons: (1) Systematic communication failures—family was not informed that a healed sacral wound re-emerged in Mar…

geriatric medicinegeneral practicecommunicationsystemrozex
SAaged care2013-11-29

Coroner's Finding: BETTS Lawrence

9y · Male·sigmoid volvulus

Lawrence Betts, a 9-year-old Aboriginal boy with Goldenhar syndrome and developmental disability including pica (ingesting foreign substances), died from sigmoid volvulus complicated by ingestion of soil, sand, and stone…

paediatricsgastroenterologysupervisionsystem
VICaged care2020-01-30

Finding into death of Adele Di Quinzio

86y · Female·Sepsis complicating sacral decubitus ulceration in the setting of recent surgica…

Mrs Di Quinzio, an 86-year-old woman with multiple comorbidities, was discharged from hospital to a supported residential service (SRS) after hip fracture surgery. She required two-person assistance for mobility and was …

geriatric medicineorthopaedic surgerysystemcommunicationcefalexin
SAhospital2017-02-01

Coroner's Finding: KLINGBERG Briony Caitlin

10y · Female·Multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infecti…

…virus (HSV) infection. She presented to the Women's and Children's Hospital on day 3 of pharyngitis with ulceration of the tonsillar fossae. The registrar suggested admission for observation and fluids, but the consultan…

paediatricsemergency medicinediagnosticcommunicationceclor
VIChospital2019-04-04

Finding into death of Isabella Estelle Rees

1y · Female·Gastrointestinal haemorrhage due to aorto-oesophageal fistula caused by lodged b…

Isabella Rees, aged 14 months, presented to Sunshine Hospital ED four times over 19 days with fever, vomiting and later haematochezia. A button battery lodged in her oesophagus caused progressive caustic injury leading t…

emergency medicinepaediatricsdiagnosticcommunicationondansetron
QLDhospitalNew2026-06-09

Inquest into the death of Rosemarie Campbell

62y · Female·Acute bacterial peritonitis and pneumonia

Rosemarie Campbell, 62, died 27 February 2022 from acute bacterial peritonitis and pneumonia following a Roux-en-Y gastric bypass at Wesley Hospital. Pre-operative failures: The surgeon inadequately investigated her refl…

bariatric surgeryanaesthesiadiagnosticproceduralesomeprazole
WAhospital2009-02-01

Inquest into the Death of Fox

62y · Male·Acute Gastrointestinal Haemorrhage in association with Acute on Chronic Peptic U…

Kenneth Charles Fox, 62, presented to Fremantle Hospital ED on 12 April 2006 with a gastrointestinal bleed after fainting. He was diagnosed with a massive bleed causing hypovolaemic shock and stabilized with fluid resusc…

emergency medicinegeneral surgerydiagnosticdelayaspirin
QLDhospital2008-11-28

McVey, Oliver Steven

67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent clo…

Oliver Steven McVey, a premature twin born at 31 weeks gestation weighing 1036g, died from complications of endotracheal tube re-insertion at 67 days of age. Following successful surgical ligation of a patent ductus arte…

neonatologycardiothoracic surgeryproceduralcommunication
WAhospital2006-05-31

Inquest into the Death of nilon

67y · Female·Pneumonia (streptococcus pneumoniae) in a woman receiving treatment for carcinom…

Peggy Anne Nilon, 67, died from pneumonia (streptococcus pneumoniae) at St John of God Hospital Bunbury on 25 February 2003. Her small cell lung cancer had achieved remission following chemotherapy and radiotherapy. A cr…

oncologygeneral practicediagnosticcommunicationcisplatin

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.