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NSWhospital2025-07-22

Inquest into the death of Prabha Arunkumar

41y · Female·multiple stab wounds to the neck

This inquest examined the death of Prabha Arunkumar, a 41-year-old computer programmer who died from multiple stab wounds to the neck sustained during an attack in Parramatta Park on 7 March 2015. She was transported to …

trauma surgeryvascular surgery
NSWcommunity2024-05-31

Inquest into the death of BC

78y · Male·multiple blunt force injuries

An 78-year-old man with no prior mental health history died by suicide after jumping from a cliff following a police response to a welfare concern. He had recently undergone cardiac surgery and was managing physical reha…

cardiothoracic surgerycardiology
NSWhospital2024-01-29

Inquest into the death of Sean Montgomery

70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia

70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…

cardiothoracic surgerygeneral surgerydiagnosticcommunicationmorphine
NSWhospital2023-09-13

Inquest into the death of Jeffrey Blundell

44y · Male·cardiogenic shock, on a background of severe tricuspid valve regurgitation, seve…

Jeffrey Blundell, a 44-year-old man with severe intravenous drug use history, died from cardiogenic shock secondary to severe tricuspid valve regurgitation caused by infective endocarditis from non-sterile injection prac…

cardiothoracic surgerycardiologyhydromorphone
NSW2023-03-14

Inquest into the death of James Brown

70y · Male·Hemopericardium due to ruptured aortic dissection contributed to by hypertension

Mr James Brown, a 70-year-old prisoner with a long-standing history of hypertension and atrial fibrillation, died from hemopericardium due to ruptured aortic dissection. He collapsed with chest pain while at work in the …

emergency medicinevascular surgeryprazosin
NSWhospital2022-06-09

Inquest into the death of Steve FESUS

60y · Male·metastatic atrial sarcomatoid tumour

Steve Fesus, aged 60, died in custody at Prince of Wales Hospital from metastatic atrial sarcomatoid tumour. He had been diagnosed with cardiac cancer in 2016, underwent surgery, and was in remission until metastases wer…

oncologycardiologypazopanib
NSWhospital2022-02-07

Inquest into the death of Jose Manuel XAVIER

64y · Male·Consequences of metastatic oesophageal carcinoma with Stanford B dissection thor…

Jose Manuel Xavier, a 64-year-old prisoner, died from metastatic oesophageal carcinoma with a contributing Stanford B thoracic aortic dissection. He was diagnosed with oesophageal cancer in July 2019 after presenting wit…

palliative caregastroenterologymorphine
NSWhospital2021-04-16

Inquest into the death of Kelvin MOULDS

61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a c…

Kelvin Moulds, a 61-year-old man, died of hypoxic encephalopathy following a cardiac arrest caused by self-removal of a central venous catheter (CVC) on day 14 post-bilateral lung transplant. The CVC was still in situ de…

cardiothoracic surgerytransplant medicinecommunicationsystemoxycodone
NSWhospital2020-03-04

Inquest into the death of Paul MORTIMER

65y · Male·ischaemic heart disease following complications of colorectal surgery

A 65-year-old man with significant comorbidities (cardiomyopathy, diabetes, obesity) underwent colorectal surgery for adenocarcinoma. Post-operative course was complicated by anastomotic breakdown causing sepsis on day 1…

colorectal surgeryintensive careproceduralsystemenoxaparin
NSWhospital2019-11-21

Inquest into the death of Ross MARTIN

56y · Male·acute pentobarbitone toxicity

Ross Martin, a 56-year-old man with a long history of depression, died from acute pentobarbitone (Nembutal) toxicity obtained online, combined with toxic levels of zopiclone, less than two weeks after premature discharge…

psychiatrygeneral practicediagnosticcommunicationpentobarbitone
NSWhospital2018-11-09

Inquest into the death of Alexander Costello

37y · Male·Haemopericardium secondary to aortic dissection

Alexander Costello, 37, presented to Gunnedah Hospital ED with acute onset severe chest pain, back pain, diaphoresis and nausea. Dr G., the sole ED physician, conducted initial assessment including ECG and troponin testi…

emergency medicinegeneral practicediagnosticcommunicationmorphine
NSWhospital2016-04-08

Inquest into the death of Ida ROMEO

59y · Female·acute cardiogenic shock, with acute mechanical obstruction of a remote mechanica…

Ida Romeo, 59, died during cardiac catheterisation at Liverpool Hospital when a pressure wire became trapped in her mechanical aortic valve. She had consented to a right heart study to investigate suspected constrictive …

cardiologyintensive careconsentcommunicationfentanyl
NSW2016-03-06

Inquest into the death of Laurence Bede O Connor

73y · Male·Combined effects of ischaemic heart disease and chronic obstructive pulmonary di…

A 73-year-old man in prison custody died from combined ischaemic heart disease and chronic obstructive pulmonary disease. He had a significant cardiac history including aortic repair and endocarditis, plus severe COPD wi…

cardiothoracic surgeryrespiratory medicinewarfarin
NSWhome2015-09-26

Inquest into the death of Kerryn Foale

22y · Female·ventricular fibrillation resulting from hypertrophic cardiomyopathy when her imp…

22-year-old woman with hypertrophic cardiomyopathy died from ventricular fibrillation when her implantable cardioverter defibrillator (ICD) failed to terminate the arrhythmia due to lead insulation failure caused by chro…

cardiologycardiothoracic surgerysystem
NSWhospital2015-08-17

Inquest into the death of Manjit SINGH

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

Manjit Singh, a 33-year-old Indian 457 visa worker, died from hypoxic respiratory failure following a pneumonectomy for treatment of severe pulmonary tuberculosis. He had latent TB identified pre-arrival in India. Critic…

respiratory medicinecardiothoracic surgerydiagnosticcommunicationtuberculosis medications
NSWhospital2014-07-11

Inquest into the death of Toni Ann PEADON

52y · Female·laceration of the superior vena cava and right atrium during defibrillator lead …

A 52-year-old woman with a history of syncope and mitral valve prolapse, who had an implanted defibrillator, underwent a percutaneous laser lead extraction procedure at Westmead Hospital to remove and replace defective l…

cardiologycardiothoracic surgerysystemdelay

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