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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
VIChospital2026-04-17

Finding into death of White-Wolf Patricia Mclellan

44y · Female·Pulmonary thromboembolism complicating a fractured left ankle (not operated), su…

A 44-year-old woman died from pulmonary thromboembolism 27 days after sustaining a Weber B ankle fracture from a fall. She was managed conservatively with a CAM boot then below-knee cast, with progressive immobilisation …

emergency medicineorthopaedic surgerysystemcommunicationtenecteplase
VIChospital2026-04-16

Finding into death of Damien Mark Stone

53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures

Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…

emergency medicineneurologydiagnosticcommunicationoxycodone
VICcommunity2026-02-19

Finding into death of Kathleen Smith

53y · Female·Unascertained (presumed drowned)

Kathleen Smith, a 53-year-old podiatrist, disappeared on 15 July 2024 and is presumed to have drowned at Sorrento Back Beach. She was experiencing severe anxiety about upcoming foot surgery due to severe flatfoot deformi…

general practiceorthopaedic surgerycommunicationdelaysertraline
VIChospital2025-08-21

Finding into death of Andrew William Barr

54y · Male·Complications of pelvic and spinal fractures sustained in a fall in man with Dow…

Andrew William Barr, a 54-year-old man with Down syndrome and Alzheimer's dementia, died from complications of pelvic and spinal fractures sustained in a fall. Following his mother's death in January 2021 and his Februar…

orthopaedic surgerypalliative carecommunicationsystemanti-epileptic medication
VIChospital2025-04-17

Finding into death of Graeme William Dimsey

62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…

A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…

orthopaedic surgeryinfectious diseasesdiagnosticproceduralceftriaxone
VICaged care2025-03-14

Finding into death of Maria Grazia Nardiello

90y · Female·Surgical repair of fractured neck of femur sustained in a fall complicated by CO…

Maria Grazia Nardiello, aged 90, died following surgical repair of a fractured neck of femur sustained in a fall at an aged care facility, complicated by COVID-19 infection. She was pushed by another resident with dement…

geriatric medicineorthopaedic surgerysystem
VIChome2025-01-20

Finding into death of Kim Marie Bartolo

47y · Female·Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol…

Kim Bartolo, a 47-year-old woman with depression, anxiety, alcohol use disorder and chronic conditions, died from mixed drug toxicity involving multiple prescription medications. She was admitted to Brunswick Private Hos…

psychiatryorthopaedic surgerycommunicationmedicationvenlafaxine
VICcommunity2024-12-18

Finding into death of Kevin John Harris

38y · Male·Pulmonary thromboembolism in the setting of deep vein thrombosis

Kevin Harris, a 38-year-old man with obesity, sustained a left tibial plateau fracture from a workplace fall on 27 December 2022. His general practitioner managed the injury conservatively with rest, ice, and anti-inflam…

general practiceorthopaedic surgerysystem
VICaged care2024-04-30

Finding into death of Jean Meyer

96y · Female·complications following a fractured distal right femur

A 96-year-old woman died from complications of a hip fracture sustained when pushed by a fellow resident with severe dementia at an aged care facility. The resident pressed the call bell for help, but the system was non-…

geriatric medicineorthopaedic surgerysystem
VICaged care2024-03-28

Finding into death of Shirley Hill Jones

85y · Female·Complications of a left ankle fracture (operated)

An 85-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, hypertension, prior stroke) sustained a left ankle fracture requiring surgical repair. A significant delay occurred in removing her pla…

geriatric medicineorthopaedic surgerycommunicationdelayoxycodone
VIChospital2024-03-04

Finding into death of Frank Allen Hall-Bentick

69y · Male·Septic arthritis of the knee

Frank Hall-Bentick, a 69-year-old man with severe muscular dystrophy and restrictive lung disease dependent on 24-hour BiPAP, presented to Austin Hospital with septic arthritis of the right knee and septic shock. A multi…

intensive careemergency medicineantibiotics
VICaged care2023-11-30

Finding into death of Catherine Mary Reid

80y · Female·multiple injuries in the setting of a fall

Catherine Mary Reid, aged 80, died from multiple fractures sustained in a fall during a mechanical hoist transfer at a disability care facility. While being transferred from wheelchair to bed using an overhead ceiling ho…

geriatric medicineorthopaedic surgeryprocedural
VIChospital2023-11-29

Finding into death of Danielle Elizabeth Peters

40y · Female·Sepsis secondary to ureteritis, pyelonephritis and aspiration pneumonia with a c…

A 40-year-old woman with cerebral palsy, autism, and schizoaffective disorder living in specialist disability accommodation died from sepsis secondary to ureteritis, pyelonephritis, and aspiration pneumonia. She had sust…

general medicineinfectious diseases
VIChome2023-10-12

Finding into death of Amanda Jane Harris

36y · Female·Stab wound to the right chest

Amanda Jane Harris, 36, was fatally stabbed by her intimate partner Daniel Eckersley on 7 July 2018 in Cranbourne North, Victoria. Eckersley was prescribed high-dose tramadol (700-800mg daily) for chronic pain over 22 mo…

general practicepain medicinemedicationcommunicationtramadol
VIChospital2023-10-10

Finding into death of Mary Veronica Morrow

68y · Female·Pulmonary embolism due to deep venous thrombosis secondary to fractured left dis…

Mary Morrow, aged 68, died from pulmonary embolism and deep vein thrombosis following a fractured left ankle sustained in Queensland on 23 June 2021. She received appropriate VTE prophylaxis initially (enoxaparin) but th…

emergency medicineorthopaedic surgerycommunicationsystemenoxaparin
VIChospital2023-07-19

Finding into death of Daryl William Nioa

74y · Male·Pulmonary thromboembolism secondary to deep vein thrombosis in the setting of re…

A 74-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis following a cervical spinal fracture. He presented to rural ED with mental health concerns, was restrained by security guards after …

emergency medicineneurosurgerydiagnosticdelayclonazepam
VICaged care2023-01-16

Finding into death of Heather Amy Robertson

83y · Female·Complications arising from a fall with C2 fracture and neck of femur fracture

An 83-year-old woman with dementia, Alzheimer's disease, and a prior hip fracture sustained injuries from a fall in her aged care facility's dining room. Staff were absent from the dining room for approximately 7 minutes…

geriatric medicineemergency medicinesupervisionsystem
VIChospital2022-09-07

Finding into death of Mr AB

17y · Male·Hypoxic ischaemic encephalopathy due to hanging

A 17-year-old male who transitioned from female died by hanging on 21 April 2020, seven days after discharge from psychiatric inpatient care. He had complex medical needs including chronic back pain, spinal fusion, post-…

psychiatryemergency medicinesystemcommunicationquetiapine
VICaged care2022-03-30

Finding into death of Arsinoi Karamoskos

89y · Female·complications of a femoral neck fracture (operated) in an elderly woman with mul…

An 89-year-old woman with dementia suffered a femoral neck fracture when pushed by another dementia patient in a secure geriatric unit corridor. She underwent surgical repair but deteriorated post-operatively and died 10…

geriatric medicineorthopaedic surgery

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