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NSW2026-05-06

Inquest into the death of Arianna Maragol

1y · Female·Rapidly developing Streptococcus pneumoniae infection leading to invasive pneumo…

Arianna Maragol, a 16-month-old girl, died from rapidly developing Streptococcus pneumoniae infection leading to invasive pneumococcal disease while in childcare on 24 August 2018. Key clinical lessons emerged: (1) Pneum…

paediatricsemergency medicinesystemcommunicationibuprofen
NSWhospital2019-10-25

Inquest into the death of Peter SMITH

67y · Male·Gas gangrene with antecedent cause of Clostridium septicum septicaemia

Peter Smith, 67, presented to Cooma Hospital with severe leg muscle cramps and pain on 6 February 2018. Despite appropriate pain management and initial investigation suggesting rhabdomyolysis, he rapidly deteriorated and…

emergency medicinegeneral practicesystemmorphine
TAShospital2019-02-19

Coroner's Finding: Beltz, Sarah Rose

17y · Female·bacterial sepsis (septic shock) due to Neisseria meningitidis infection

Sarah Rose Beltz, a 17-year-old student, died of bacterial sepsis (septic shock) secondary to Neisseria meningitidis infection on 12 July 2018. She contracted meningococcal disease and presented to Hobart Private Hospita…

emergency medicineinfectious diseases
WAcommunity2017-11-20

Inquest into the Death of JDC (Subject to Suppression Order)

17y · Female·fungal brain infection and infarction complicating fungal infection of a scalp l…

A 17-year-old Aboriginal girl in state care died on 22 May 2012 from fungal brain infection and stroke. On 19 April 2012, she caused a motor vehicle crash by driving unlicensed while intoxicated, sustaining severe head a…

emergency medicinetrauma surgerydiagnosticsystemalcohol
TAShospital2017-09-22

Coroner's Finding: Hosking, Jason Mathew Henry

34y · Male·Staphylococcus aureus sepsis and endocarditis

Jason Hosking, 34, presented to ED with vomiting, diarrhoea, fever, tachycardia and hypotension on 10 November 2014. Blood tests by 11.23am showed markedly elevated inflammatory markers (CRP 234.3, neutrophils 10.8, elev…

emergency medicinemicrobiologydiagnosticcommunicationoxycodone
VIChospital2016-10-24

Finding into death of Child A

3y · Male·thrombotic microangiopathy

A 3-year-old child died from thrombotic microangiopathy (haemolytic uraemic syndrome) secondary to Shiga toxin-producing E. coli infection, likely acquired from consumption of unpasteurised milk. Early presentation to GP…

paediatricsemergency medicineondansetron
VIChospital2014-12-04

Finding into death of Leroy William Scott

1y · Male·Staphylococcus aureus septicaemia of unknown origin

Leroy William Scott, a 15-month-old boy, presented to Geelong Hospital with fever, lethargy, and poor oral intake. He was triaged as semi-urgent and not seen by a doctor until 5 AM, 8 hours later. Blood cultures drawn at…

paediatricsemergency medicinediagnosticcommunicationparacetamol
TAShospital2014-09-19

Coroner's Finding: Tetley, Barry Lindsay

72y · Male·sepsis of undetermined source (pneumonia or spinal epidural abscess)

A 72-year-old man presented to ED with back pain, fever, elevated inflammatory markers (CRP 77.9, high WBC), hypotension (98/59 mmHg at 6:30am), hyponatremia, and hypoalbuminemia—all consistent with sepsis. Despite these…

emergency medicineintensive carediagnosticcommunication
TAS2013-11-06

Coroner's Finding: Sullivan, Craig

18y · Male·rupture of a left frontal cerebral abscess

An 18-year-old male detainee at Ashley Youth Detention Centre died from rupture of a left frontal cerebral abscess likely caused by sinus infection. Craig was admitted on remand in early October 2010 and presented with i…

infectious diseasesneurosurgerysystemdelay
VIChome2013-05-07

Finding into death of JOVO VRANJESEVIC

57y · Male·thalamic haemorrhage with ventricular extension

A 57-year-old man with hypertension and atrial fibrillation suffered a massive thalamic haemorrhage while at home and was declared brain dead at hospital. His organs were donated to three recipients who all died within s…

transplant medicineintensive care
VIChospital2013-05-07

Finding into death of Carmelina Rachela Sirianni

63y · Female·Lymphocytic choriomeningitis virus (LCMV)-like virus infection; post failed rena…

A 63-year-old woman received a renal transplant from a cadaveric donor who had died of cerebral hemorrhage. She developed delayed graft function and deteriorated post-operatively, ultimately dying from a novel lymphocyti…

nephrologytransplant medicinecommunicationsystem
WAhospital2012-09-14

Inquest into the Death of dawkins

17y · Female·Acute Lymphocytic Meningitis and Focal Myocarditis

Amy Lee Dawkins, 17, presented twice to Rockingham General Hospital ED within two weeks with severe headaches, myalgias, and vomiting. On 28 December 2008, she was discharged with a diagnosis of viral upper respiratory t…

emergency medicinegeneral medicinecommunicationsystemcitalopram
SAhospital2012-07-31

Coroner's Finding: KISON Trinity Isabel

<1y · Female·respiratory failure due to congenital pneumonia with hyaline membrane disease ca…

Trinity Kison, a 21-hour-old neonate born at 35 weeks gestation, died from respiratory failure due to congenial pneumonia caused by streptococcus pneumoniae. The maternal high vaginal swab taken one week before delivery …

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
VICaged care2012-06-25

Finding into death of Broughton Hall Inquest

Unknown·Salmonella infection contributing to deaths in gastroenteritis outbreak

Four elderly residents of Broughton Hall aged care facility died during a 2007 Salmonella gastroenteritis outbreak. A three-day delay in notifying the Department of Health (April 7 to April 10) prevented early identifica…

infectious diseasesgeriatric medicinediagnosticcommunication
SAhospital2012-03-07

Coroner's Finding: MILLER Allan Kenneth

56y · Male·disseminated nocardiosis involving central nervous system, kidneys, liver and th…

Allan Kenneth Miller, 56, died from disseminated nocardiosis (rare bacterial infection) that was not diagnosed during his 12-day RAH admission. Clinicians initially suspected metastatic lung cancer based on presentation …

respiratory medicineinfectious diseasesdiagnosticdelayenoxaparin
QLDhospital2007-10-01

Fogarty, Kevin Edward

37y · Male·Community acquired pneumonia as a result of melioidosis infection

Kevin Fogarty, a 37-year-old power lineman, died from melioidosis-related community-acquired pneumonia at Winton Hospital after a 4-day admission. He likely contracted melioidosis through occupational exposure to mud dur…

general practiceemergency medicinediagnosticcommunicationdiazepam

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