212 results
38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…
Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute car…
47y · Male·Pneumonia (1(a)), Motor neurone disease (1(b))
Raymond Cassar, a 47-year-old man with motor neurone disease requiring ventilatory support, died of pneumonia at a disability accommodation service. He had been diagnosed with a chest infection on 19 June 2018 and prescr…
37y · Male·Mixed Drug Toxicity (Oxycodone, Quetiapine, Pregabalin and Clonazepam)
A 37-year-old man died from mixed drug toxicity (oxycodone, quetiapine, pregabalin, clonazepam) after ingesting unknown quantities of his own medications in an ED. He presented with trauma symptoms four days post-motor v…
48y · Female·Hypoxic/Ischaemic Encephalopathy; Aspiration of Food with Respiratory Arrest wit…
Kathryn O'Rourke, aged 48, a resident with severe intellectual disability and dysphagia in a disability residential care facility, aspirated a piece of toast during breakfast on 10 May 2018 and died from hypoxic-ischaemi…
37y · Female·Multiple drug toxicity
Sharni Dee Connolly, a 37-year-old registered nurse turned naturopath, died from multiple drug toxicity following a hamstring injury requiring opioid analgesia. She was prescribed excessive quantities of pregabalin (105m…
68y · Male·Hanging
Kent Thomas, aged 68, died by hanging in December 2018. He had experienced chronic tinnitus since 2013 which severely impacted his mental health and quality of life. Despite referral to mental health services and a reaso…
40y · Female·Cerebral oedema of unknown aetiology with probable contribution from Hashimoto's…
Sarah Louise Rose, aged 40, died from cerebral oedema of unknown aetiology with probable contribution from Hashimoto's encephalopathy. She had been diagnosed with Hashimoto's thyroiditis in late 2011 and prescribed thyro…
90y · Male·aspiration pneumonia, vascular dementia, ischaemic heart disease, congestive car…
Raymond Albert Daly, aged 90, died of aspiration pneumonia complicated by vascular dementia, ischaemic heart disease, congestive cardiac failure and chronic renal failure whilst a resident at the Roy Fagan Centre under a…
89y · Male·multi-organ failure on a background of advanced dementia and small cell lung can…
An 89-year-old prisoner with advanced dementia and small cell lung cancer died from multi-organ failure whilst in lawful custody at Yatala Labour Prison. He entered prison aged 83 with complex medical needs including isc…
76y · Female·left lower lobe pneumonia complicating metapneumovirus infection
Maria Astachnowicz, aged 76, died from left lower lobe pneumonia complicating metapneumovirus infection at Lyell McEwin Hospital. She had extensive psychiatric history (schizoaffective disorder/bipolar) with chronic ment…
75y · Female·general inanition and pneumonia on a background of end-stage dementia
75-year-old woman with end-stage mixed dementia (vascular and Alzheimer's) died from general inanition and pneumonia. She was detained under a Mental Health Act Inpatient Treatment Order due to severe aggression and beha…
79y · Male·myocardial infarction
Brian Davies, 79, died of myocardial infarction while under an Inpatient Treatment Order for Alzheimer's dementia at Noarlunga Hospital. He presented with cognitive decline following his partner's death and developed agi…
68y · Male·unascertained
A 68-year-old man with multiple chronic medical conditions including peripheral neuropathy, chronic pain, atrial fibrillation, dysphagia, and depression disappeared on 25 June 2017. He left home, drove his car to Lanceli…
5y · Female·aspiration of vomit with microscopic early pneumonia, in a child with a history …
A five-year-old girl with cerebral palsy and epilepsy resulting from non-accidental head injuries at two months old died from aspiration of vomit with early pneumonia. Critical lessons: bruising in non-ambulant infants i…
54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking
A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to…
35y · Male·acute vomit aspiration in a man with acute large intestine obstruction (severe m…
Stephen Michael Kell, a 35-year-old man with treatment-resistant schizophrenia, died at Graylands Hospital from acute vomit aspiration in the setting of acute large bowel obstruction and clozapine-induced gastrointestina…
78y · Male·Subarachnoid haemorrhage (bilateral) and occipital fracture
A 78-year-old man with vascular and Alzheimer's dementia died from bilateral subarachnoid haemorrhage and occipital fracture sustained when he forcefully opened a bathroom door into his face while under an Inpatient Trea…
70y · Female·end stage dementia
Carole Ann Dunstan, a 70-year-old woman with end-stage dementia, died of natural causes at Repatriation General Hospital on 17 June 2017 while subject to a Level 3 Inpatient Treatment Order. She had been admitted followi…
52y · Male·C2, C3, C4 spinal injury sustained from a fall secondary to seizures
A 52-year-old man with cerebral palsy, epilepsy, and intellectual disability living in disability accommodation fell in the bathroom after a seizure and sustained cervical spine fractures (C2-C3-C4). He was admitted to h…
78y · Female·advanced dementia (end stage)
Mrs Lorraine Ashton, aged 78, died of advanced dementia (end stage) at Repatriation General Hospital on 23 September 2017. She had Primary Progressive Aphasia diagnosed in 2014 following non-Hodgkin's lymphoma treatment.…
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