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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
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
WAhospital2023-08-30

Inquest into the Death of Kevin George HOWLETT

83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)

An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …

vascular surgerygeneral medicinediagnosticcommunication
WAhospital2022-06-08

Inquest into the Death of Salvatore Giovanni OTRANTO

68y · Male·Complications following myocardial infarction and its treatment in a man with mu…

Salvatore Otranto, a 68-year-old prisoner with multiple severe comorbidities including ischaemic heart disease, diabetes, COPD, and chronic kidney disease, died from complications of myocardial infarction and its treatme…

cardiologyintensive careproceduralenoxaparin
WA2022-02-04

Inquest into the Death of Robert William ROMAN

55y · Male·Subdural haematoma in a man with diabetes mellitus and chronic kidney disease (r…

A 55-year-old Aboriginal man with end-stage renal disease, diabetes, ischaemic heart disease and COPD died from a spontaneous subdural haematoma while undergoing haemodialysis in prison custody. He presented with headach…

nephrologyemergency medicinesystemcommunicationaspirin
WAhome2021-08-26

Inquest into the Death of Baby E (Name Subject to Suppression Order)

0y · Male·Complications of VATER syndrome and sacrococcygeal teratoma

Baby E was a 7-month-old neonate with VATER syndrome and sacrococcygeal teratoma who died from complications of these conditions. He was born prematurely at 30 weeks, requiring intubation and ventilation, and remained in…

neonatologynephrology
WAhospital2020-06-03

Inquest into the Death of Brian Vincent ATTWELL

77y · Male·cardiac failure in an elderly man with valvular heart disease and other co-morbi…

Brian Attwell, a 77-year-old sentenced prisoner with multiple chronic conditions including diabetes, chronic renal failure, peripheral vascular disease, and valvular heart disease, died of cardiac failure in hospital. He…

geriatric medicinecardiology
WAhospital2020-06-03

Inquest into the Death of Michael Warren DYBALL

56y · Male·bronchopneumonia complicated by multiorgan failure and hypoxic ischaemic encepha…

Michael Dyball, a 56-year-old prisoner with chronic kidney disease, hepatitis C, and treated oropharyngeal squamous cell carcinoma, collapsed in his prison cell and suffered cardiopulmonary arrest on 28 April 2016. He di…

nephrologyoncologydarbepoetin alfa
WAhome2019-12-19

Inquest into the Death of Child AC

8y · Female·renal failure due to focal segmental glomerulosclerosis

A child with complex neurodevelopmental conditions (cerebral palsy/Rett Syndrome) and focal segmental glomerulosclerosis developed progressive renal failure and died at home on palliative care. The coroner found the medi…

paediatricsneurology
WAhospital2019-09-23

Inquest into the Death of Dylan James RILEY

16y · Male·pulmonary embolism secondary to nephrotic syndrome

Dylan Riley, a 16-year-old with steroid-responsive minimal change nephrotic syndrome, died from a massive pulmonary embolism (PE) on 1 August 2015. He presented to Rockingham Hospital with dyspnoea, hypoxia, tachycardia …

nephrologyintensive caredelayenoxaparin
WAhospital2019-07-22

Inquest into the Death of Arthur James BONNEY

59y · Male·ischaemic heart disease in the context of acute-on-chronic kidney failure associ…

Arthur James Bonney, a 59-year-old prisoner with advanced cardiac disease, chronic kidney disease, and diabetes, underwent a CT scan with iodinated contrast on 30 July 2015 at Fiona Stanley Hospital. Critical failures oc…

radiologycardiologydiagnosticproceduraliodinated contrast medium
WAhospital2019-05-31

Inquest into the Death of Aurelio Monterlegre CRUZ

80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…

Aurelio Monterlegre Cruz, an 80-year-old man with complex medical conditions including chronic renal failure, ischaemic heart disease, diabetes, and COPD, died of bronchopneumonia complicating terminal palliative care wh…

nephrologypalliative carecommunicationdelayinsulin
WAhospital2017-05-03

Inquest into the Death of Edith Catherine BEE

80y · Female·Gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm …

An 80-year-old woman with multiple comorbidities (COPD, renal impairment, cardiac disease) underwent complex endoluminal repair of a thoracoabdominal aortic aneurysm at a private hospital. The procedure required use of C…

vascular surgerygeneral surgeryproceduralsystem
WAhospital2016-05-18

Inquest into the Death of Janice May SAULYS

69y · Female·multi-organ failure due to sepsis of unknown origin

A 69-year-old woman with diabetes, cardiac disease, and vulnerable kidneys died from multi-organ failure due to sepsis of unknown origin. She presented to a rural hospital on 28 June 2012 with vomiting, dehydration, and …

emergency medicinegeneral practicesystemdelay
WAhospital2014-12-30

Inquest into the Death of Gheorghe Gruici

71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…

Gheorghe Gruici, a 71-year-old life-sentenced prisoner, died of organ failure from chronic renal failure, infective endocarditis, and chest infection. Over 15 years in custody, he developed multiple comorbidities includi…

general medicinenephrologyomeprazole
WAmental health- 11 April 2014

Inquest into the Death of Amanda Alison GILBERT

47y · Female·bronchopneumonia in context of ischaemic heart disease, chronic renal failure, a…

Amanda Gilbert, aged 47, died from bronchopneumonia with background ischaemic heart disease, chronic renal failure, and hypoxic brain injury from a 1985 hanging attempt. She had been an involuntary patient at Graylands H…

psychiatrygeneral medicinesystemdelaylithium
WA2013

Inquest into the Death of Bropho, Robert Charles

81y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis

Robert Charles Bropho, an 81-year-old Aboriginal man imprisoned since 2008 with severe medical comorbidities including insulin-dependent diabetes, hypertension, chronic renal failure, and severe ischaemic heart disease, …

cardiologygeneral medicinecommunicationsysteminsulin
WAhospital2012

Inquest into the Death of Keogh

38y · Female·Pulmonary Thromboembolism

Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…

general surgeryintensive carecommunicationdelaywarfarin
WAhospital

Inquest into the Death of Robert Paul RODDA

62y · Male·Multi-organ failure following surgical repair of ruptured abdominal aortic aneur…

Robert Paul Rodda, a 62-year-old long-term prisoner with extensive medical comorbidities including ischaemic heart disease, COPD, and a known abdominal aortic aneurysm (AAA), presented with chest pain in September 2015. …

vascular surgerycardiology

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