212 results
84y · Male·ischaemic heart disease on a background of advanced Lewy body dementia
An 84-year-old man with Lewy body dementia died from ischaemic heart disease while detained under a Mental Health Act order. He was admitted to hospital for management of aggressive behaviour related to his dementia. Dur…
85y · Female·complications of oesophageal cancer
Dorothy Williams was an 85-year-old woman with intellectual impairment and dementia who died from complications of oesophageal cancer. She was diagnosed with inoperable oesophageal cancer in 2012 and managed palliatively…
18y · Male·Aspiration pneumonia in a setting of acquired brain injury from non-accidental h…
Jay Dion Sykes, aged 18, died from aspiration pneumonia in the setting of acquired brain injury sustained non-accidentally as an infant. He had severe cerebral palsy, tetraparesis, aphasia, visual impairment, intellectua…
60y · Female·hanging
Margaret McCall, a 60-year-old woman with chronic regional pain syndrome and longstanding anxiety and depression, died by hanging. She received multiple ketamine infusions for pain management, with cessation of fentanyl …
40y · Male·combined drug toxicity in a man with asthma (undiagnosed) and sleep apnoea
Anthony Travaglini, a 40-year-old with schizoaffective disorder, severe sleep apnoea, and undiagnosed asthma, died from combined drug toxicity on a psychiatric high-dependency unit. Critically, his earlier clinical recor…
71y · Male·Sepsis due to bronchopneumonia and sacral ulcer
Mr John Knight, aged 71, died from sepsis secondary to bronchopneumonia in a psychiatric inpatient unit after five months admission for frontotemporal dementia management. His complex behavioural and cognitive decline re…
5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia
Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trac…
59y · Female·head injury
Ms Athiel Deng, a 59-year-old Sudanese refugee, was fatally assaulted by her son Majang Ngor during an acute psychotic episode induced by cannabis and methamphetamine use. Ngor had a documented first psychotic episode in…
53y · Female·hanging
Maria Nigro, a 53-year-old woman with depression and recent medication overdose, was admitted involuntarily to Werribee Mercy Hospital's Low Dependency Unit (LDU) on 4 February 2009. Despite a risk assessment on 9 Februa…
smoke inhalation and burns from deliberately-lit fire (primary cause varies by i…
Fourteen elderly residents died in a deliberately-lit fire at Quakers Hill Nursing Home on 18 November 2011, set by drug-dependent nurse Roger Dean to destroy evidence of medication theft. Dean had worked while visibly i…
29y · Male·Combined methadone, diazepam and clonazepam toxicity in a man commencing a metha…
Phillip Black, age 29, died from combined methadone, diazepam and clonazepam toxicity after commencing methadone maintenance therapy. He presented to Dr D. on 23 September 2010 seeking to re-commence MMT, having previous…
38y · Male·Organizing pneumonia with loculated pleural effusion in the setting of drug use …
Paul Kanis, a 38-year-old man with schizoaffective disorder, drug dependency, diabetes, and asthma, died from organizing pneumonia with loculated pleural effusion in the setting of methadone and benzodiazepine use. The c…
49y · Female·lobar pneumonia in the setting of Down's syndrome and progressive dementia
Diane Wilson, aged 49 years with Down's syndrome and progressive dementia, died of lobar pneumonia following gradual physical deterioration from March to September 2013. She presented to hospital with seizures secondary …
78y · Male·urinary tract infection in a man with dementia and epilepsy
William Morrison Nunan, a 78-year-old man with intellectual disability, dementia, epilepsy, and chronic urinary tract infections managed with a suprapubic catheter, died of urosepsis at a hospice after admission for end-…
41y · Male·Upper airway obstruction from ingestion of dirt in an intellectually impaired ma…
Darren Hannah, a 41-year-old man with severe intellectual disability, autism, partial blindness and longstanding pica disorder, died from upper airway obstruction after ingesting large quantities of dirt in the backyard …
31y · Female·plastic bag asphyxia
Kirstan McRae-Jansen, a 31-year-old woman with chronic schizophrenia, borderline personality disorder, and substance abuse, died by plastic bag asphyxia using an LPG bottle. She was under Community Treatment Order with E…
39y · Male·respiratory failure as a result of the interaction of prescribed medication and …
Mark Richard Gleeson, 39, died from respiratory failure caused by the combined effect of prescribed antipsychotic/anxiolytic medications (olanzapine, quetiapine, clonazepam) and alcohol consumed within hours of discharge…
42y · Female·Heroin toxicity, self-administered
Tracylee Brannigan, a 42-year-old woman in custody at Dillwynia Correctional Centre, died from heroin toxicity on 24-25 February 2013. The coroner found she self-administered a potentially fatal dose of heroin after bein…
37y · Female·Mixed drug toxicity (methadone, diazepam, clonazepam, amisulpride, olanzapine, h…
Susan Robb, 37, was admitted involuntarily to Northern Hospital Psychiatric Unit with deteriorating mental health and on a Community Treatment Order. Three weeks after self-discontinuing methadone, the treating team re-c…
70y · Female·Aspiration pneumonia, associated with Huntington's disease
Beryl Watson, a severely disabled 70-year-old with advanced Huntington's disease and dementia, died of aspiration pneumonia following a three-week respite stay at a BUPA aged care facility. Critical failures included: om…
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