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SAhospital2026-03-30

Coroner's Finding: Chadha, Hemant and Battagodage, Sachintha Nandula

Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…

Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…

emergency medicinegeneral practicediagnosticcommunicationdiazepam
SAaged care2026-02-12

Coroner's Finding: D Angelo, Adelina

88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…

An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatra…

general practicegeriatric medicinediagnosticcommunicationfurosemide
SAhospital2025-11-14

Coroner's Finding: Menzies, Jason Douglas

33y · Male·Marburg variant of multiple sclerosis

Jason Menzies, aged 33, died in custody from Marburg variant multiple sclerosis after rapid neurological deterioration. He initially presented with urinary retention on 1 December 2022, which was appropriately investigat…

emergency medicinegeneral medicineamitriptyline
SAhospital2025-07-03

Coroner's Finding: Provis, Adam James

50y · Male·in-hospital cardiac arrest on a background of seizures and atheroembolic cerebro…

A 50-year-old man with bipolar affective disorder, hypertension, anxiety, depression and history of alcohol abuse died from in-hospital cardiac arrest on a background of seizures and atheroembolic cerebrovascular disease…

psychiatryneurologythiamine
SAhospital2025-05-20

Coroner's Finding: Freeman, Keith Vivian

71y · Male·end-stage cardiac failure on a background of ischaemic heart disease with dilate…

Keith Freeman, aged 71, died in custody from end-stage cardiac failure with ischaemic heart disease and dilated cardiomyopathy. He had complex cardiac history including previous CABG, aortic valve replacement, and implan…

cardiologyemergency medicinedelayfurosemide
SAhospital2025-05-20

Coroner's Finding: Lane, Kevin Roy

81y · Male·inanition complicating traumatic brain injury and disseminated malignancy

An 81-year-old man with metastatic bowel cancer suffered a traumatic brain injury from a fall, resulting in multiple intracerebral haemorrhages and cerebral contusions. He was delirious and presented challenging behaviou…

neurosurgerygeneral medicine
SAaged care2025-03-31

Coroner's Finding: Kettlestring, Jacqueline Collette

64y · Female·acute bronchopneumonia complicating Alzheimer's dementia with head injury

A 64-year-old woman with advanced Alzheimer's dementia died from acute bronchopneumonia following a head injury sustained in an unwitnessed fall. She was under a guardianship order with special powers at the time. Follow…

geriatric medicinegeneral medicine
SA2024-09-13

Coroner's Finding: Morrison, Gerald Douglas

61y · Male·ischaemic heart disease with left ventricular hypertrophy

A 61-year-old Aboriginal man died in prison custody from ischaemic heart disease with left ventricular hypertrophy. He had significant cardiac risk factors including type 2 diabetes, hypercholesterolaemia, age, male sex,…

cardiologygeneral medicinemetformin
SA2024-09-13

Coroner's Finding: Mortess, Noel Allen

75y · Male·End stage myelodysplastic syndrome and end stage renal failure on a background o…

A 75-year-old man died in prison custody from end-stage myelodysplastic syndrome and renal failure on a background of ischaemic heart disease, hypertension, valvular disease, and metastatic prostate cancer. He was admitt…

general medicinehaematologydelaysystemcefuroxime
SAhospital2024-06-19

Coroner's Finding: Ferns, Patricia Dorothy

79y · Female·cardiogenic shock following repair of fractured right femur on a background of a…

Mrs Patricia Ferns, aged 79, died from cardiogenic shock following femur fracture repair, complicated by underlying aortic valve stenosis, atherosclerotic disease and hypertension. She fell at home and was admitted with …

cardiologyorthopaedic surgery
SAaged care2024-05-22

Coroner's Finding: Donato, Anthony

85y · Male·blunt craniocerebral trauma following a fall

Anthony Donato, aged 85, died from blunt craniocerebral trauma following an unwitnessed fall at an aged care facility. He had dementia, hypertension, sleep apnoea, and previous falls. He was assessed as medium fall risk …

geriatric medicineemergency medicine
SAaged care2024-01-19

Coroner's Finding: Elliott, Ronald Arthur

80y · Male·aspiration pneumonia on a background of severe oropharyngeal dysphagia and chron…

Ronald Arthur Elliott, aged 80, died of aspiration pneumonia complicated by severe oropharyngeal dysphagia and COPD following a hip fracture. He fell on 12 June 2020, underwent left hip hemiarthroplasty at Flinders Medic…

orthopaedic surgerygeneral medicine
SAaged care2023-12-22

Coroner's Finding: LENS, Christopher

64y · Male·hypoxic-ischaemic encephalopathy and its complications following cardiac arrest …

Christopher Lens, a 64-year-old man with schizophrenia under guardianship at a nursing home, died from hypoxic-ischaemic encephalopathy following cardiac arrest due to upper airway obstruction after choking on a peanut b…

geriatric medicinespeech pathologysystemcommunication
SAhospital2023-04-11

Coroner's Finding: Rerich, Josef

78y · Male·multi-organ failure complicating neck of femur fracture (operated) on a backgrou…

A 78-year-old man with multiple comorbidities (heart failure, renal disease, COPD) suffered a neck of femur fracture from an unwitnessed fall at an aged care facility. Post-operatively he deteriorated with acute renal fa…

orthopaedic surgerygeneral medicinehaloperidol
SAhospital2022-08-15

Coroner's Finding: Kelley, John Michael

83y · Male·General inanition and aspiration pneumonia on a background of end-stage Alzheime…

An 83-year-old man with end-stage Alzheimer's dementia died from general inanition and aspiration pneumonia while subject to a Mental Health Act order in hospital. He had experienced two episodes of aspiration pneumonia …

psychiatrygeriatric medicineantibiotics
SAhospital2022-06-10

Coroner's Finding: McCallum, Myrtle Olive

95y · Female·acute left subdural haematoma complicating anticoagulant therapy for deep vein t…

A 95-year-old woman with multiple comorbidities including congestive heart failure was admitted with suspected pneumonia and cellulitis. She developed deep vein thrombosis and was started on enoxaparin anticoagulation. S…

psychiatrygeneral medicineenoxaparin
SA2022-03-30

Coroner's Finding: Hohol, Peter

68y · Male·decompensated heart failure with pulmonary hypertensive crisis complicated by pn…

Peter Hohol, a 68-year-old prisoner with significant cardiac comorbidities including ischaemic and dilated cardiomyopathy, died from decompensated heart failure with pulmonary hypertensive crisis complicated by pneumonia…

cardiologygeneral medicine
SAhospital2022-03-30

Coroner's Finding: Dunn, Julie Michele

56y · Female·sepsis secondary to disseminated pancreatic adenocarcinoma

Julie Michele Dunn, a 56-year-old female prisoner, died of sepsis secondary to disseminated pancreatic adenocarcinoma. She had presented months earlier with gastrointestinal symptoms (weight loss, nausea, vomiting, epiga…

general medicineoncologydiagnostictramadol
SAhospital2022-03-29

Coroner's Finding: Duthie, Norman Alec

96y · Male·hospital acquired pneumonia on a background of advanced Alzheimer's dementia

Norman Alec Duthie, a 96-year-old man with advanced Alzheimer's dementia, died of hospital-acquired pneumonia following admission to Noarlunga Hospital. He was placed on a Mental Health Act Inpatient Treatment Order due …

geriatric medicinepsychiatry
SAhospital2022-03-29

Coroner's Finding: Foster, Clive Anthony

76y · Male·end-stage renal failure

A 76-year-old man died of end-stage renal failure while imprisoned. He had pre-existing hypertension, diabetes, and stage 3 chronic kidney disease. During his final year in custody, he experienced acute kidney injury sup…

general medicinenephrology

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