21 results
55y · Male·decompensated liver failure in a man with metastatic hepatocellular carcinoma, w…
Tony Ruich, a 55-year-old sentenced prisoner, died from decompensated liver failure due to metastatic hepatocellular carcinoma with terminal palliative care. He had pre-existing cirrhosis diagnosed in 2012, likely from h…
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
24y · Male·Hypoxic Ischaemic Encephalopathy due to hanging
Jayke Aleckson, 24, died by hanging in a non-BDRP compliant prison health cell while on remand at Marngoneet Correctional Centre in October 2018. Key clinical lessons: (1) Multiple unmet requests for antidepressant medic…
46y · Male·sepsis following haemorrhoidectomy
46-year-old Justin Mark Dobson died from sepsis following a routine haemorrhoidectomy on 17 July 2019. He was discharged to the ward overnight but deteriorated significantly from 11:00 am on 18 July, showing hypotension,…
70y · Female·Cause of death could not be determined - available evidence does not allow a fin…
A 70-year-old woman died unexpectedly at home in August 2017. Initially certified as hypertensive heart disease without autopsy, the death was later investigated as a potential homicide following allegations by her forme…
23y · Male·Stab wounds to the chest and back
Hassan Jeng, a 23-year-old remand prisoner with a history of mental illness and substance use, was fatally stabbed multiple times in his cell at Port Phillip Prison on 1 January 2018. CCTV footage clearly documented the …
44y · Male·Subarachnoid haemorrhage due to ruptured anterior communicating artery aneurysm
A 44-year-old man died in prison from subarachnoid haemorrhage due to ruptured anterior communicating artery aneurysm. He had pre-existing hypertension, depression, anxiety, and chronic pain. While at the remand centre, …
59y · Male·mixed drug toxicity (tramadol and sertraline), likely serotonin syndrome
A 59-year-old man died from mixed drug toxicity involving tramadol and sertraline, likely precipitating serotonin syndrome. He was prescribed tramadol 150mg morning and 100mg evening (total 250mg daily), but evidence ind…
66y · Male·chest injuries sustained in a motor vehicle collision (motorcyclist)
A 66-year-old motorcyclist died from chest injuries after a motor vehicle collision during a police traffic interception operation. The incident involved a police officer signalling an oncoming driver to slow down to fac…
87y · Female·intentional inhalation of tissue paper leading to upper airway obstruction and h…
Paquita Goldberg, an 87-year-old woman with dementia, BPSD, and paranoia, died from intentional inhalation of tissue paper while admitted to Baringa aged psychiatry unit under a Mental Health Act order. Over 7-8 February…
54y · Male·aspiration pneumonia caused by multiple drug toxicity
Paul Lau, aged 54, died from aspiration pneumonia caused by opioid toxicity following ACL reconstruction surgery. The death resulted from a prescribing error where anaesthetist Dr K. inadvertently prescribed a 100mcg/hou…
37y · Male·Acute epiglottitis
A 37-year-old male prisoner presented with a sore throat and was assessed by a doctor who found only minor inflammation and no signs of bacterial infection, treating conservatively with analgesia. Eight hours later, afte…
79y · Male·hypoxic brain injury due to cardio-respiratory arrest caused by opioid toxicity
Yongxing Wang, 79, died from hypoxic brain injury caused by opioid toxicity from combined morphine and oxycodone. After a minor back injury on 21 August, he received a cortisone injection on 22 August with complications.…
50y · Male·aspiration of vomit in a man with focal coronary arteriosclerosis
Subhas Chandra, a 50-year-old man, died between 3-4 November 2013 from aspiration of vomit in the setting of focal coronary arteriosclerosis. He had been involved in a physical altercation with a housemate shortly before…
23y · Female·chronic hydrocephalus with brain swelling
A 23-year-old registered nurse with undiagnosed chronic hydrocephalus presented to the ED with neck pain, headache and vomiting. Dr B. assessed her briefly without formal examination or detailed history, prescribed ketor…
66y · Male·multiple organ failure associated with the combined effects of complications of …
Daniel Lahengking, a 66-year-old Indonesian visiting family in Esperance, was diagnosed with rheumatoid arthritis by locum GP Dr H. and prescribed methotrexate 5-10mg daily, a grossly excessive dose (normal: 7.5-20mg wee…
84y · Female·septicaemia secondary to septic arthritis of the left knee
An 84-year-old woman presented to hospital with acute left knee swelling and pain. Initial assessment at Ashford Hospital ED reasonably excluded septic arthritis based on borderline blood tests and absence of fever, thou…
45y · Male·intracerebral haemorrhage caused by rupture of arterial aneurysm
A 45-year-old man with an intracerebral haemorrhage from a ruptured aneurysm presented to an emergency department and general practice on multiple occasions in October 2005 with headache, vomiting, dizziness, and neck st…
74y · Male·cardiac and renal failure complicating treatment of infected ischaemic toes resu…
Glenn Howard Raphael, 74-year-old admitted for infected ischaemic toe secondary to diabetes mellitus. During his 17-day hospital stay, he developed acute renal failure leading to cardiac arrest and death. Critical failur…
67y · Female·perforated gastric ulcer; morphine toxicity also made a significant contribution
Mrs Lillian Shaw, a 67-year-old obese woman with a history of NSAID use, presented with vomiting and abdominal pain over 36 hours. A GP visited three times without performing adequate physical examination, failed to insp…
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