Coronial
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TAShospital2026-01-21

Coroner's Finding: de-identified KW

87y · Female·right thigh haematoma as a consequence of a periprosthetic fracture of the right…

An 87-year-old woman with multiple comorbidities (diabetes, atrial fibrillation, peripheral vascular disease) sustained a periprosthetic fracture requiring distal femur replacement. She deteriorated significantly during …

orthopaedic surgerygeriatric medicinediagnosticsystem
TASaged care2026-01-07

Coroner's Finding: Bird, Allan Roy

92y · Male·Consequences of accidental fall at RACF: post-operative delirium, left femoral i…

A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner ident…

geriatric medicineorthopaedic surgerydiagnosticsystembenzodiazepine
TASaged care2025-12-12

Coroner's Finding: Mitchelmore, Susan

70y · Female·pneumonia and post-surgical course following repair of neck of femur fracture, i…

Susan Mitchelmore, a 70-year-old woman with multiple comorbidities including COPD, ischaemic heart disease, diabetes, and bipolar disorder, was a resident in an aged care facility under a Mental Health Act Treatment Orde…

geriatric medicinepsychiatryolanzapine
TASaged care2025-10-14

Coroner's Finding: de-identified XT

86y · Female·Hypostatic pneumonia due to the consequences of a right pubic rami fracture and …

An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…

geriatric medicineemergency medicinediagnosticcommunication
TASaged care2025-05-26

Coroner's Finding: de-identified GJ

94y · Male·aspiration pneumonia due to stroke following surgery to repair fracture of neck …

A 94-year-old man with dementia died from aspiration pneumonia following a stroke after hip surgery. The stroke and hip fracture resulted from being pushed by another resident with Alzheimer's dementia at an aged care fa…

geriatric medicineorthopaedic surgerysystemdelayoxazepam
TAShospital2025-04-30

Coroner's Finding: Warn, Kenneth

86y · Male·aspiration pneumonia following injuries sustained in a motor vehicle crash and p…

Kenneth Warn, 86, sustained a T12 burst fracture and bilateral pleural effusions from a motor vehicle crash on 1 March 2024 while a passenger in a Mercedes panel van. The driver suddenly lost control on Tea Tree Road; th…

emergency medicineorthopaedic surgery
TAShospital2025-01-20

Coroner's Finding: Lowe, Wayne Anthony

58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humeru…

Wayne Anthony Lowe, aged 58, died of multiorgan failure due to sepsis following repeated humeral fractures sustained in falls. He was admitted with a right proximal humeral fracture from an intoxicated fall, discharged a…

orthopaedic surgerygeneral medicinesystemdelay
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
TASaged care2024-12-18

Coroner's Finding: Martin, Shirley Dorothy

91y · Female·exacerbation of behavioural and psychological symptoms of dementia following sur…

Shirley Dorothy Dawn Martin, an 91-year-old with advanced Alzheimer's disease and multiple comorbidities, sustained a hip fracture from an unwitnessed fall at an aged care facility on 8 August 2022. She underwent surgica…

geriatric medicineorthopaedic surgery
TAShospital2024-11-26

Coroner's Finding: de-identified FG

57y · Male·partially suspended hanging

A 57-year-old man with longstanding alcohol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for orthopaedic injuries sustained from intentional jumping. He …

orthopaedic surgerypsychiatrycommunicationsystemdiazepam
TAShospital2024-11-04

Coroner's Finding: de-identified EK

80y · Male·haemorrhagic stroke caused by Staphylococcus aureus sepsis due to L4/5 discectom…

An 80-year-old man underwent elective microdiscectomy for spinal pain in April 2023. In late June, he developed a wound infection with Staphylococcus aureus causing discitis. Despite appropriate diagnosis and aggressive …

orthopaedic surgeryinfectious diseasesantibiotics
TASaged care2024-10-22

Coroner's Finding: Whish-Wilson, Leslie Bruce

76y · Male·hospital-acquired pneumonia, age-related frailty, consequences of left neck of f…

Leslie Bruce Whish-Wilson, 76, sustained a fall in his aged care room in January 2024, leading to a right femoral neck fracture requiring surgical repair. Post-operatively, he developed hospital-acquired pneumonia compli…

geriatric medicineorthopaedic surgerysystemdelay
TAShospital2024-10-11

Coroner's Finding: Vieth, Karl Heinz

92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…

A 92-year-old man with complex cardiac history was admitted to Royal Hobart Hospital with chest pain and atrial fibrillation. He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, …

general medicineemergency medicinesystemdelaymelatonin
TAShospital2024-10-10

Coroner's Finding: Hill, James Fredrick

74y · Male·small intestinal ischaemia caused by aortic atherosclerosis

A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clea…

emergency medicineorthopaedic surgerydiagnosticcommunication
TASaged care2024-09-27

Coroner's Finding: Webberley, Patricia

87y · Female·pneumonia following complications from a fractured left wrist sustained in a fal…

Mrs Webberley, 87, resident of a residential aged care facility (RACF), sustained an unwitnessed fall on 1 November 2021 resulting in a left wrist fracture (Colles' fracture). She was initially assessed at the RACF but n…

geriatric medicineorthopaedic surgerysystem
TAShospital2024-09-12

Coroner's Finding: Chapman, Jane Ann

74y · Female·Post-operative exacerbation of delirium and terminal functional deterioration du…

Jane Ann Chapman, 74, presented to hospital with delirium, fever and suspected urinary tract infection. She fell from an Emergency Department trolley bed, sustaining a neck of femur fracture requiring surgery. Post-opera…

emergency medicineorthopaedic surgeryproceduralsystem
TAShospital2024-05-10

Coroner's Finding: Constantine, Georgiou

51y · Male·cerebral fat embolism due to surgery for multiple traumatic injuries sustained i…

Andrew Constantine Georgiou, 51, died from cerebral fat embolism following multiple severe leg and pelvic injuries sustained in a vehicle crash. He crossed the centre line on Tea Tree Road and collided with a truck. Para…

trauma surgeryorthopaedic surgery
TAShospital2024-03-27

Coroner's Finding: Leary, Kane

17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…

Kane Mathew Leary, 17, died from a stroke (left middle cerebral artery infarction) following a motorbike collision. The critical clinical lesson involves a missed diagnosis of left internal carotid artery dissection on i…

emergency medicineneurosurgerydiagnosticcommunicationmorphine
TAShome2024

Coroner's Finding: Heraghty, Susanna Elizabeth

68y · Female·mixed prescription drug toxicity (oxycodone, metoprolol, diazepam)

Ms Heraghty, a 68-year-old woman with multiple comorbidities including obesity (BMI 47.3), atrial fibrillation, COPD, and severe chronic pain, died from mixed prescription drug toxicity (oxycodone, metoprolol, diazepam) …

orthopaedic surgeryanaesthesiaoxycodone
TASaged care2023-12-18

Coroner's Finding: Reeve, Aubrey Charles

98y · Male·comminuted pertrochanteric fracture of left hip sustained in mechanical fall

A 98-year-old man with osteoporosis, dementia, and ischaemic heart disease sustained a comminuted pertrochanteric hip fracture in a fall at his residential aged care facility on 24 July 2023, dying four days later. He ha…

geriatric medicineemergency medicinesystemcommunication

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