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VIChospital2026-04-28

Finding into death of Ronald William Beaumont

74y · Male·Acute myocardial infarction complicated by multiple organ failure

Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…

cardiologyorthopaedic surgerymedicationcommunicationaspirin
VIChospital2026-01-23

Finding into death of MD

82y · Male·Complications of large bowel obstruction in a man with diverticular disease and …

An 82-year-old man died from complications of large bowel obstruction secondary to a sigmoid mass while incarcerated at Port Phillip Prison. He presented with abdominal pain and vomiting following a fall, and imaging con…

general surgerycolorectal surgerywarfarin
SA2025-12-08

Coroner's Finding: Mountford, Raymond Malcolm Edward

82y · Male·Ischaemic and hypertensive heart disease

An 82-year-old man with extensive medical comorbidities including ischaemic heart disease, triple vessel coronary artery disease (previously bypass grafted), diabetes, chronic kidney disease, and dementia died suddenly i…

cardiologygeriatric medicinefurosemide
VIChospital2025-12-08

Finding into death of Jamie Lee Argent

38y · Male·Diabetic ketoacidosis secondary to pyelonephritis in a man with insulin dependen…

A 38-year-old man with insulin-dependent diabetes, partial blindness, gastroparesis, seizures, chronic kidney disease and peripheral vascular disease died from diabetic ketoacidosis precipitated by pyelonephritis. He had…

emergency medicineendocrinologylamotrigine
VIChospital2025-12-01

Finding into death of Larelle Sheridan Dean

51y · Female·Multiorgan failure in the setting of WHO Class III obesity, chronic excessive al…

A 51-year-old woman with WHO Class III obesity, chronic alcohol consumption, and anaemia died of multiorgan failure following admission with community-acquired pneumonia and respiratory failure. She presented with abdomi…

general medicineemergency medicinehydromorphone
NSW2025-09-15

Inquest into the death of Robert Sievers

81y · Male·COVID-19 infection on a background of Type 2 Diabetes and end stage chronic kidn…

Robert Sievers, an 81-year-old man incarcerated since 2001, died from COVID-19 infection on a background of type 2 diabetes and end-stage chronic kidney disease. Despite multiple warnings about vaccination, Sievers refus…

geriatric medicinepalliative careantiviral medication
SAaged care2025-09-11

Coroner's Finding: Glenn, Millicent

89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…

An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…

general practicegeriatric medicinemedicationdiagnosticgentamicin
QLDhospital2025-08-11

Inquest into the death of John Reginald Wright

79y · Male·Complications of peripheral vascular disease with Type 2 Diabetes Mellitus, atri…

John Reginald Wright, a 79-year-old remand prisoner, died from complications of peripheral vascular disease with diabetes, atrial fibrillation, cardiomyopathy and delirium. He was transferred to Princess Alexandra Hospit…

vascular surgerygeneral medicineglicazide
VIChospital2025-07-08

Finding into death of KD

48y · Female·Combined effects of cardiac hypertrophy, chronic obstructive pulmonary disease a…

KD, a 48-year-old woman with chronic schizo-affective disorder, end-stage renal failure, COPD, cardiac hypertrophy and obesity, died from combined natural causes while under assessment order in psychiatric care. She pres…

psychiatryintensive careolanzapine
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…

emergency medicineintensive carediagnosticproceduralhydromorphone
TAShospital2025-04-11

Coroner's Finding: Decision in relation to Martin 'Marjorie' Harwood

38y · Female·end stage renal failure (Stage 5 chronic kidney disease)

Ms Harwood, a 38-year-old transgender woman with end-stage renal disease, died of natural causes following refusal of dialysis. Her mother claimed the death was suicide prompted by fear of returning to prison following a…

nephrologygeneral medicine
VIChospital2025-04-01

Finding into death of ZSQ

81y · Male·Community acquired pneumonia in a man with acute on chronic renal failure

An 81-year-old man with chronic respiratory disease and renal failure died from community-acquired pneumonia complicated by acute-on-chronic renal failure. He presented to hospital on 25 April 2023 with respiratory failu…

intensive carerespiratory medicinediagnosticdelayadrenaline
WAhospital2025-02-21

Inquest into the Death of Fabian Alec COFFIN

51y · Male·complications of myocardial infarction in association with ischaemic heart disea…

A 51-year-old prisoner died from complications of myocardial infarction with ischaemic heart disease. He had multiple cardiovascular risk factors including type-2 diabetes, hypertension, high cholesterol, chronic kidney …

cardiologyemergency medicinediagnosticinsulin
TASaged care2025-01-14

Coroner's Finding: Rickard-Simms, Adrienne Rosemary

75y · Female·postoperative delirium/exacerbation of community acquired pneumonia following le…

A 75-year-old woman with chronic kidney disease, anemia, and significant mobility impairment fell in her aged care facility despite documented high falls risk and appropriate preventive measures. She sustained a neck of …

geriatric medicineorthopaedic surgery
VIChospital2024-12-09

Finding into death of Elizabeth Shine

64y · Female·End stage renal failure in the setting of sepsis

Elizabeth Shine, a 64-year-old NDIS participant living in Specialist Disability Accommodation, died from end-stage renal failure complicated by sepsis. She presented with a blocked parotid gland treated with antibiotics.…

general medicinenephrologyantibiotics
VIChospital2024-12-09

Finding into death of Debra Louise Goold

61y · Female·Decompensated liver failure - Child's Pugh B cirrhosis secondary to renal failur…

Debra Louise Goold, a 61-year-old NDIS participant living in Specialist Disability Accommodation, died from decompensated liver failure (Child's Pugh B cirrhosis) and renal failure. She was admitted to Ballarat Base Hosp…

hepatologygeneral medicine
WAhospital2024-09-24

Inquest into the death of Raymond Sydney CHEEK

89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…

Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarin…

emergency medicineendocrinologymedicationsystemryzodeg insulin
NSWhospital2024-09-19

Inquest into the death of Denis Ives

78y · Male·COVID-19 pneumonitis on a background of ANCA nephropathy, hypertension, and diab…

Denis Ives, a 78-year-old man with type 1 diabetes, chronic kidney disease stage 4, ANCA nephropathy and hypertension, died of COVID-19 pneumonitis while in custody at Long Bay Correctional Centre. He tested positive for…

emergency medicineinfectious diseases
SAhospital2024-09-13

Coroner's Finding: Zarrella, Dominic

88y · Male·aspiration pneumonia complicating vascular dementia and metastatic prostate canc…

An 88-year-old man with vascular dementia, metastatic prostate cancer, and chronic kidney disease died of aspiration pneumonia 15 days after admission to hospital under a Mental Health Act inpatient treatment order. He w…

oncologypsychiatry
SAhospital2024-06-19

Coroner's Finding: Leane, Stewart Anthony

62y · Male·end stage renal failure complicating oxalate crystal nephropathy with contributi…

Stewart Anthony Leane, 62, died from end-stage renal failure due to oxalate crystal nephropathy with contributing head injury. He had complex medical needs including dialysis-dependent kidney failure, schizophrenia, and …

nephrologyneurology

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