24 results
74y · Male·Pulmonary thromboembolism due to right deep vein thrombosis
Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond t…
63y · Male·Aspiration pneumonia in the setting of functional decline in a man with an intel…
A 63-year-old man with intellectual disability, cerebral palsy, dysphagia, and COPD died from aspiration pneumonia following functional decline. He had a three-month hospital admission with multiple complications includi…
70y · Male·advanced left frontal glioblastoma (operated)
A 70-year-old male prisoner died from advanced left frontal glioblastoma. The tumour was identified when he presented with acute stroke-like symptoms (facial droop, weakness, confusion) in July 2018 while imprisoned. He …
40y · Male·Bronchial Asthma
Ricardo Arquero, a 40-year-old man serving a prison sentence, died from acute bronchial asthma at Glen Innes Correctional Centre on 19 August 2019. He had a documented history of asthma since childhood and was provided w…
66y · Male·Complications of chronic obstructive pulmonary disease. A significant contributi…
Walter Clough, aged 66, died from complications of COPD and cardiomegaly while incarcerated. He had significant respiratory compromise from prior chest trauma causing hemidiaphragm paralysis. Days before death, he was ho…
8y · Male·acute exacerbation of chronic asthma
An 8-year-old boy with undertreated chronic asthma presented to North West Regional Hospital with acute exacerbation. Initial assessment underestimated severity. Despite initial improvement with salbutamol, ipratropium a…
36y · Male·bronchial asthma
Nathan Reynolds, a 36-year-old Aboriginal man with severe asthma, died from bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease man…
74y · Male·Ischaemic heart disease and coronary atherosclerosis
Mr Robert Howlett, a 74-year-old man with extensive comorbidities including chronic lung disease, hypertension and severe hearing disability, died of ischaemic heart disease and coronary atherosclerosis while in custody …
9y · Female·Acute exacerbation of asthma on a background of anaphylaxis
A 9-year-old girl with known egg allergy and asthma died from acute exacerbation of asthma on a background of anaphylaxis after consuming a Cadbury Chocolate Chip Cookie containing egg. The cookie was purchased in packag…
61y · Female·respiratory failure consistent with end-stage chronic obstructive airways disord…
A 61-year-old woman with chronic obstructive airways disease, liver disease, depression, and alcohol dependence died from respiratory failure. Her general practitioner prescribed a contraindicated combination of central …
47y · Female·hypoxic ischaemic encephalopathy complicating systolic cardiac arrest in the set…
Ms Ling-Ling Ang, aged 47, died from hypoxic ischaemic encephalopathy and cardiac arrest following severe allergic asthma exacerbation during the November 2016 Melbourne thunderstorm asthma epidemic. She had known asthma…
29y · Male·acute asthma
A 29-year-old male with known asthma and hay fever died from acute asthma during the November 2016 thunderstorm asthma event in Melbourne. He presented to Ballarat Hospital on 21 November with severe asthma, was treated …
37y · Male·Acute asthma (thunderstorm asthma event)
37-year-old male died from acute asthma during the unprecedented Melbourne thunderstorm asthma event (21-22 November 2016). He had moderate to severe asthma with suboptimal preventer medication use and recently diagnosed…
70y · Male·combined effects of severe pulmonary emphysema, ischaemic heart disease and rece…
A 70-year-old man with severe COPD, dementia and a history of sexually inappropriate behaviour died following an assault by another resident with dementia. The coroner found institutional failures in care standards inclu…
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…
46y · Female·Dilated cardiomyopathy (acute complication with sudden cardiac arrhythmia)
A 46-year-old woman with bipolar/schizoaffective disorder, poorly controlled type 2 diabetes, morbid obesity, severe obstructive sleep apnoea, and pulmonary hypertension died from acute dilated cardiomyopathy with sudden…
78y · Male·cardiomegaly with left ventricular hypertrophy and atherosclerotic cardiovascula…
Ronald William Hopkins, aged 78, died in Mount Gambier Prison on 20 April 2014 from cardiomegaly with left ventricular hypertrophy and atherosclerotic cardiovascular disease, with contributing chronic obstructive pulmona…
38y · Male·Pulmonary thromboembolism due to bilateral deep calf vein thrombi
A 38-year-old man with schizo-affective disorder, bipolar disorder, and asthma presented to the emergency department with presumed pneumonia based on fever, pleuritic chest pain, and respiratory symptoms. His general pra…
<1y · Female·perinatal asphyxia
Baby Kylie Hamilton, a 3-day-old neonate, died from perinatal asphyxia following emergency Caesarean delivery during her mother's induced labour. The mother had gestational diabetes and the fetus showed concerning CTG ab…
Unknown·Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…
Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…
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