Coronial

31 results for undiagnosed diabetes

SAcommunity2016-08-01

Coroner's Finding: ONG Hock An

58y · Male·ischaemic heart disease

…ease while evading lawful apprehension during an immigration operation in rural South Australia. He had undiagnosed underlying cardiac disease with cardiomegaly, myocardial fibrosis, and significant left coronary artery…

perindopril
VIChome2025-07-24

Finding into death of Jill Hughes

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

…e complications 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, …

infectious diseasesendocrinologydelaydiagnostic
VICcommunity2021-08-16

Finding into death of Phillip John Sealey

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

… frequency, nocturia, blurred vision, dizziness and vomiting. The GP diagnosed hypertension and suspected diabetes mellitus, ordering blood tests for the following day. No point-of-care glucose testing was performed desp…

general practiceemergency medicinediagnosticdelayfentanyl
NT2007-03-09

Inquest into the death of Patrick Heenan

50y · Male·Coronary atherosclerosis

…sport to the medical centre where CPR and defibrillation were administered. Autopsy revealed previously undiagnosed severe coronary atherosclerosis (80% stenosis), chronic hepatitis, diabetes, and hypertension. The coro…

general practiceemergency medicinemetformin
VIChome2019-08-01

Finding into death of Caleb Harley Pearson

17y · Male·Diabetic ketoacidosis

Caleb Pearson, a 17-year-old with undiagnosed Type 1 diabetes, presented with pharyngitis and was diagnosed and treated for a throat infection by his…

emergency medicinepaediatricsdiagnosticcommunicationpholcodine
NSWhospital2023-02-10

Inquest into the death of Anzac Sullivan

38y · Male·Combined effects of coronary atherosclerosis and cardiomegaly, with methylamphet…

…t increased his arrhythmia risk. No police physical contact caused his death. Clinical lessons include: undiagnosed advanced coronary artery disease can present first as sudden cardiac death; stimulant drugs significant…

cardiologyforensic medicinedelaymethamphetamine
SAhospital2011-09-23

Coroner's Finding: DUBBIOSO Roberto

34y · Male·cardiomegaly with contributing aspiration

A 34-year-old man with paranoid schizophrenia, morbid obesity, type 1 diabetes, and undiagnosed sleep apnoea died from cardiomegaly with contributing aspiration while detained under th…

psychiatryemergency medicinediagnosticsystem
WAcommunity2009-04-24

Inquest into the Death of Halford

17y · Female·Multi System Failure following acute onset (Acute Diabetic Ketoacidosis) Diabete…

Lee Rebecca Halford, a 17-year-old girl, died of acute diabetic ketoacidosis (DKA) following undiagnosed Type 1 diabetes. She initially presented to a GP with vomiting on 27 February 2007, diagnosed with gast…

general practiceemergency medicinediagnosticcommunicationmetoclopramide
SAhospital2018-07-27

Coroner's Finding: CUTTS Charles Desmond

70y · Male·aspiration pneumonia due to seizures

70-year-old man with insulin-dependent diabetes, cognitive impairment, depression, alcohol abuse history, and seizure disorder died from aspiration pneum…

emergency medicinepsychiatryrisperidone
WAhospital2005-03-03

Inquest into the Death of Giovanni Bertoncini

72y · Male·acute gangrene of colon with probable perforation along with bowel obstruction a…

Giovanni Bertoncini, a 72-year-old man with diabetes and cardiac disease, presented to Sir Charles Gairdner Hospital on Christmas Day 2002 with acute abdomina…

emergency medicinegeneral medicinediagnosticdelayparacetamol
QLDcommunity2007-01-19

Tyssen, Mario Emmy

45y · Male·Coronary artery disease due to severe atherosclerosis; acute myocardial infarcti…

…medical assessments in 2004. He had uncontrolled risk factors including smoking, poorly controlled Type 2 diabetes, and hypercholesterolaemia. The coroner found no failure of duty of care, as staff could not reasonably i…

cardiologycorrectional healthmetformin
VIC2013-05-21

Finding into death of Takashi Le Minh

34y · Male·Acute intracranial haemorrhage, malignant hypertension, renal artery stenosis

…tension on 13 June, was transferred to hospital, diagnosed with bilateral renal artery stenosis and two undiagnosed brain lesions, then returned to prison on 16 June. His anticoagulation management was complex; warfarin…

cardiologynephrologywarfarin
SAhospital2018-03-29

Coroner's Finding: BUTSON Graham Joseph

81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…

Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrill…

orthopaedic surgerygeneral medicinesystemwarfarin
ACThospital2009-04-28

Inquest Into The Death Of Stacey And Courtney Meas

Female·Stacey Meas: severe closed head injury from motor vehicle collision. Courtney Me…

…o deaths resulted from a motor vehicle collision caused by a driver with poorly managed insulin-dependent diabetes. Stacey Meas, a pregnant woman, died from head injuries sustained when the driver's car struck hers at a …

endocrinologyemergency medicinesysteminsulin
VIChospital2025-10-28

Finding into death of Kenneth James Anderson

85y · Male·Liver ischaemia and portal vein thrombosis complicating emergency cholecystectom…

…neth James Anderson, an 85-year-old man with intellectual disability and multiple comorbidities including diabetes, pancreatitis, and gallstones, died following emergency cholecystectomy for acute cholecystitis with Miri…

general surgeryintensive careantibiotics
SAmental health2003-01-10

Coroner's Finding: MYNHART Johann George

77y · Male·bilateral pulmonary emboli complicating deep vein thrombosis (left calf)

…monary emboli complicating deep vein thrombosis of the left calf. He was hospitalised for dehydration and diabetes management, then returned to psychiatric care. On 30 April, his daughter observed classic DVT signs (unil…

psychiatryemergency medicinecommunicationdelay
NSW2023-07-21

Inquest into the death of Reuben Button

34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…

…as commenced with only 1 day on Suboxone (guidelines suggest 7 days minimum), given his morbid obesity, undiagnosed sleep apnoea, and low oxygen saturation (94%). The coroner found systemic resourcing failures at Junee …

psychiatrygeneral practicediagnosticsystembuvidal
SAhospital2014-11-28

Coroner's Finding: HOGAN Constance Mary

73y · Female·general inanition due to dysphagia on a background of multiple neurological and …

A 73-year-old woman with bipolar disorder, alcohol abuse history, and multiple medical comorbidities presented with stroke-like symptoms in March 2012. Neuroimaging was unrevealing. She was detained under the Mental Heal…

neurologypsychiatry
VICcommunity2021-04-07

Finding into death of Pamela Robson Pattison

75y · Female·Haemopericardium due to dissection of the ascending aorta

…ng to the jaw, which the GP attributed to possible acute myocardial infarction based on her risk factors (diabetes, hypertension, smoking history). An ECG was performed and considered unchanged. No further investigations…

general practiceforensic medicinediagnostic
WAmental health2019-05-22

Inquest into the Death of Christopher John DEBNAM

40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…

…respiratory arrest between 6.30am and 7.10am on 21 November and could not be revived. Clinical lessons: undiagnosed cardiac disease and untreated sleep apnoea in patients requiring sedation pose serious risks; visual re…

psychiatryrespiratory medicinediagnosticcommunicationhaloperidol

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