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ACThospital2024-09-16

Inquest Into The Death Of Sharyn Kaine

73y · Female·Multi organ failure due to adhesions related bowel perforation (surgically treat…

Sharyn Kaine, a 73-year-old woman, died from multi-organ failure due to adhesions-related bowel perforation and paracetamol-induced liver failure. She was prescribed intravenous paracetamol 1g four times daily post-opera…

general surgeryanaesthesiamedicationtranscriptionparacetamol
ACThospital2019-11-06

Inquest into death of THEADORA ZAAL

75y · Female·cardiac arrest in the context of aortic stenosis (moderate to severe), coronary …

A 75-year-old woman with significant cardiac history (aortic stenosis, coronary artery disease, left ventricular hypertrophy) underwent elective ankle ulcer debridement surgery. She developed refractory hypotension post-…

anaesthesiasurgerydiagnosticsystem
ACThospital2019-06-25

Inquest into the death of Jay Alan Paterson

43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …

Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone table…

general practicepain medicinesystemproceduraloxycodone
ACThome2019-06-04

Inquest into the death of Lauren Maree Johnstone

48y · Female·Combined toxic effect of prescription and non-prescription medications including…

Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…

general practicesurgerycommunicationsystemdoxylamine
ACThospital2018-11-26

AN INQUEST INTO THE DEATH OFADRIAN CHARLES WILFRED VAN DIE

50y · Male·Multi-organ failure caused by low flow ischaemia of coeliac artery and superior …

Adrian Van Die, a 50-year-old with severe ischaemic cardiomyopathy, underwent coronary artery bypass grafting with intra-aortic balloon pump (IABP) support. The first IABP ruptured intraoperatively and was replaced. The …

cardiothoracic surgeryintensive caresystem
ACThome2018-06-25

INQUEST INTO THE DEATH OF SUELLEN EDITH DAVIS

57y · Female·Positional asphyxia caused by the combined effect of consumption of several opia…

57-year-old woman with chronic pain died from positional asphyxia caused by consumption of multiple sedative medications. She was prescribed opioids (Fentanyl, Oxycodone) and Pregabalin, but also obtained Dolased and Pro…

general practicepain medicinecommunicationsystemoxycodone
ACThospital2018-04-26

AN INQUEST INTO THE DEATH OFJOHN BELL

71y · Male·cardiac arrest due to hyperkalemia due to acute on chronic renal failure, with r…

John Bell, a 71-year-old man with history of bowel cancer, ischaemic heart disease, and chronic renal failure, underwent elective ileostomy reversal surgery. He died from cardiac arrest due to hyperkalemia and metabolic …

surgerynephrologydiagnosticsystem
ACThospital2014-03-03

Findings Into The Death Of Sukanya Thurairajah

56y · Female·hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and f…

Sukanya Thurairajah, 55-year-old with multiple comorbidities including obesity, diabetes, coronary disease, and metastatic breast cancer, underwent haemodialysis at Canberra Hospital on 29 July 2011. She had an adverse r…

anaesthesiaintensive careproceduralcommunicationhydrocortisone
ACThome2012-09-24

Inquest Into The Death Of Stephen Moon

21y · Male·cardiac arrest caused by acute bilateral pneumonia

Stephen Moon, a 21-year-old with autism and intellectual disability, died following wisdom tooth extraction complicated by ventilator-acquired pneumonia. Although discharged early from ICU after 3 days, he developed bila…

anaesthesiaintensive caredelaycommunicationpropofol
ACThospital2010-05-31

Inquest Into The Death Of Valerie Kolts

Female·retroperitoneal blood loss in a setting of anticoagulation therapy following hip…

Valerie Kolts died from retroperitoneal blood loss following hip replacement surgery while on anticoagulation therapy. The coroner found no lack of care contributed to her death. Although some clinical signs were retrosp…

orthopaedic surgeryanaesthesiaanticoagulant
ACThospital2010-04-30

Inquest Into The Death Of Meg Malaika

39y · Female·heart failure connected to a massive pulmonary embolus as a result of deep vein …

A 39-year-old woman died from acute heart failure due to massive pulmonary embolus from deep vein thrombosis two days after laparoscopic appendicectomy. She presented to ED with abdominal pain and nausea, was diagnosed w…

emergency medicinegeneral surgerymedicationcommunicationheparin
ACThospital1989-12-22

Inquest Into The Circumstances Surrounding The Death Of Alex Nicholas Mersiades

3y · Male·cerebral oedema which caused coning at the base of the brain, caused by post-ope…

A 3-year-old boy died from cerebral oedema caused by post-operative hyponatraemia following scoliosis correction surgery. The operation was successful, but severe hyponatraemia developed in the early hours of 24 April 19…

surgeryanaesthesiadiagnosticdelay

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