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SAhospital2026-03-30

Coroner's Finding: Chadha, Hemant and Battagodage, Sachintha Nandula

Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…

Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…

emergency medicinegeneral practicediagnosticcommunicationdiazepam
SAhospital2026-03-13

Coroner's Finding: Schlaefer, Norbert

69y · Male·disseminated urothelial carcinoma of the bladder (palliated), bilateral lung ade…

A 69-year-old man died in prison custody from disseminated urothelial carcinoma of the bladder, bilateral lung adenocarcinoma, and severe emphysema. He had a significant smoking history and prior asbestos exposure. His l…

oncologyrespiratory medicine
SAhospital2025-11-14

Coroner's Finding: Wallace, Peter John

67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …

Peter John Wallace, aged 67, died in custody at Lyell McEwin Hospital from hypoxic respiratory failure complicating pneumonia, pulmonary embolism, and advanced hepatocellular carcinoma. He had been imprisoned at Yatala L…

hepatologyoncologyenoxaparin
SAhospital2025-11-05

Coroner's Finding: Jackson, Dennis Charles

67y · Male·Type 2 respiratory failure due to pneumonia

Dennis Jackson, a 67-year-old from Broken Hill, underwent left upper lobe lobectomy based on a falsely positive lung biopsy contaminated with squamous cell carcinoma tissue from another patient during processing at SA Pa…

cardiothoracic surgerypathologydiagnosticsystem
SAhospital2024-05-22

Coroner's Finding: Kolega, Sime

54y · Male·multi-organ failure and sepsis complicating fulminant pneumonia with empyema (op…

A 54-year-old man died from sepsis and multi-organ failure secondary to fulminant pneumonia with empyema. He presented to his GP on 1 April 2021 with concerning signs including bilateral oedema, fever, and respiratory sy…

general practiceemergency medicinedelaysystemflixotide
SAhospital2024-05-16

Coroner's Finding: Fisher, Lynne Patricia

60y · Female·sepsis due to community acquired pneumonia

Lynne Patricia Fisher, 60, presented to Mount Barker Hospital ED on 26 September 2018 with bilateral community-acquired pneumonia and was discharged after 6.5 hours despite clinical deterioration. She collapsed at home w…

emergency medicinegeneral practicediagnosticdelayamoxicillin/clavulanate
SAhospital2024-01-19

Coroner's Finding: Le, Tu Loan

54y · Female·metastatic squamous cell carcinoma of the lung

Tu Loan Le, a 54-year-old woman on home detention release from prison, died from metastatic squamous cell carcinoma of the lung at The Queen Elizabeth Hospital on 9 May 2020. She had been diagnosed with stage 4 lung canc…

oncologypalliative care
SAprison2023-11-10

Coroner's Finding: Trotta, Giovanni

58y · Male·acute bronchopneumonia

Giovanni Trotta, aged 58, died in custody from acute bronchopneumonia. He was a vulnerable prisoner with COPD, schizoaffective disorder, and profound deafness. Clinical lessons include: (1) hospital discharge summaries m…

emergency medicinerespiratory medicinediagnosticcommunicationclozapine
SAhome2022-12-22

Coroner's Finding: Abbott, John

69y · Male·plastic bag asphyxia and mixed drug toxicity (oxycodone and pentobarbitone)

John Abbott, aged 69, died from plastic bag asphyxia and mixed drug toxicity (oxycodone and pentobarbitone) while under home detention bail with electronic monitoring. He had a complex medical history including chronic o…

general practicepsychiatryoxycodone
SAhospital2022-08-15

Coroner's Finding: Kelley, John Michael

83y · Male·General inanition and aspiration pneumonia on a background of end-stage Alzheime…

An 83-year-old man with end-stage Alzheimer's dementia died from general inanition and aspiration pneumonia while subject to a Mental Health Act order in hospital. He had experienced two episodes of aspiration pneumonia …

psychiatrygeriatric medicineantibiotics
SAhospital2022-08-15

Coroner's Finding: Larchin, John

87y · Male·infective exacerbation of chronic obstructive lung disease

An 87-year-old man with a long smoking history and no prior diagnosis of lung disease suffered a hip fracture requiring surgery. Postoperatively, he developed delirium and hypoxia. Two Inpatient Treatment Orders were app…

orthopaedic surgerypsychiatryhaloperidol
SAmental health2022-07-08

Coroner's Finding: Cardwell, Phillip David

53y · Male·lung abscess with empyema

A 53-year-old man with schizophrenia died from lung abscess with empyema while an involuntary inpatient at a mental health facility. He had been readmitted with a respiratory infection and was treated with intravenous an…

psychiatryemergency medicinedelayclozapine
SAhospital2021-06-30

Coroner's Finding: MAZMANIDIS Kiriakos Jack

83y · Male·respiratory failure due to chronic obstructive lung disease

An 83-year-old man with chronic obstructive pulmonary disease, suspected mesothelioma, and recurrent respiratory infections presented with type 2 respiratory failure and delirium secondary to hypoxia and lower respirator…

respiratory medicineintensive carehaloperidol
SAhospital2020-11-02

Coroner's Finding: NIXON Viola Daphne

92y · Female·decompensated congestive cardiac failure secondary to haemophilus influenzae low…

A 92-year-old woman with dementia, heart disease, and COPD died from decompensated congestive cardiac failure secondary to haemophilus influenzae lower respiratory tract infection. She was admitted to psychiatric care un…

psychiatryemergency medicine
SA2020-10-12

Coroner's Finding: KEIRL Dennis Frank

63y · Male·metastatic carcinoma of the lung (small cell neuroendocrine carcinoma with poorl…

A 63-year-old male prisoner died from metastatic small cell lung cancer with adenocarcinoma features. Cancer was incidentally discovered during investigation of a deep vein thrombosis in October 2018, leading to one mont…

oncologygeneral medicinewarfarin
SAhospital2020-07-09

Coroner's Finding: SHAW Laurel Jean

84y · Female·multi-organ failure arising from Staphylococcal septicaemia

Laurel Jean Shaw, aged 84, died from multi-organ failure secondary to Staphylococcal septicaemia. She was detained under a Mental Health Act order for Lewy Body Dementia when she developed MRSA pneumonia and sepsis on 15…

intensive carepsychiatry
SAhospital2020-06-25

Coroner's Finding: KARTINYERI Laura Rose

44y · Female·multi-organ failure and polypharmaceutical overdose on a background of severe ch…

Laura Rose Kartinyeri, aged 44, died from multi-organ failure and polypharmaceutical overdose on a background of severe COPD. She had a long history of substance abuse, non-compliance with treatment, and hospital present…

respiratory medicineintensive carepregabalin
SAhospital2020-06-18

Coroner's Finding: BOES Johannes Josephus

92y · Male·pulmonary thromboembolic disease on a background of infective exacerbation of ch…

A 92-year-old man with chronic obstructive pulmonary disease, vascular dementia, and heart disease died from pulmonary thromboembolism complicated by respiratory infection. He was admitted after a fall at home, became ag…

respiratory medicineemergency medicinehaloperidol
SAhospital2020-06-18

Coroner's Finding: BOYCE Ian Charles

85y · Male·hospital acquired pneumonia on a background of metastatic colorectal carcinoma

An 85-year-old man died from hospital-acquired pneumonia on a background of metastatic colorectal cancer. He was admitted to hospital with psychotic depression, suicidal ideation, and severe malnutrition after two years …

psychiatrygeriatric medicine
SAhospital2020-06-18

Coroner's Finding: WILKS Deslandes

79y · Male·Pneumonia complicating ischaemic heart disease and dementia

A 79-year-old man with advanced Alzheimer's disease, ischaemic heart disease, and behavioural disturbance died of pneumonia while on a Level 2 Inpatient Treatment Order at Flinders Medical Centre. He was admitted from a …

geriatric medicinepsychiatryrisperidone

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