158 results
1y · Female·Rapidly developing Streptococcus pneumoniae infection leading to invasive pneumo…
Arianna Maragol, a 16-month-old girl, died from rapidly developing Streptococcus pneumoniae infection leading to invasive pneumococcal disease while in childcare on 24 August 2018. Key clinical lessons emerged: (1) Pneum…
1y · Male·Complications of acute lymphoblastic leukaemia
A 21-month-old boy died from sepsis secondary to pneumonia complicated by undiagnosed acute lymphoblastic leukaemia (ALL). He presented to ED on 22 March with a three-week history of intermittent fever, had seen three GP…
42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…
Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…
58y · Male·acute myocardial infarction caused by ischaemic heart disease
Gregory Merriman, a 58-year-old Aboriginal man, died from acute myocardial infarction caused by advanced ischaemic heart disease while in custody at Metropolitan Reception and Remand Centre on 27 December 2022. He experi…
57y · Female·aspiration of gastric contents caused by combined drug and alcohol toxicity resu…
A 57-year-old woman with complex medical and mental health conditions died from aspiration of gastric contents caused by combined drug and alcohol toxicity. She had severe chronic pain following abdominal surgeries, opio…
61y · Male·Right lower lobe pneumonia
Graeme William Kenny, a 61-year-old man with trisomy 21 and dementia, died from right lower lobe pneumonia on 25 December 2024 at Monash Medical Centre following palliative care. He developed upper respiratory symptoms o…
0y · Male·Streptococcus pyogenes and parechovirus infection
An eight-month-old boy in state care died from Streptococcus pyogenes and parechovirus infection. He presented to hospital twice before death with fever and ear infection symptoms. On first presentation (2 September), he…
44y · Female·Cardiac arrest in the context of several contributory factors (physical exertion…
Selesa Tafaifa, a 44-year-old woman with Samoan heritage, died in custody at Townsville Women's Correctional Centre on 30 November 2021 during physical restraint by correctional officers, including application of a safet…
26y · Male·Multi-organ failure due to pneumococcal septic shock
A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…
3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…
Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…
4y · Male·Haemophilus influenzae septicaemia with superimposed respiratory tract infection
A 4-year-old previously healthy male presented to Katherine Regional Hospital on 10 September 2023 with fever and eye pain. He was examined, found to have tachycardia (HR 156) and fever (39.2°C), and diagnosed with viral…
35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…
35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…
41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm
Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…
7y · Female·Group A Streptococcus (Streptococcus pyogenes) pneumonia with sepsis
A 7-year-old previously healthy girl died from Group A Streptococcus pneumonia with sepsis after paramedics failed to transport her to hospital despite recording a severely elevated heart rate (172 and 168 bpm) on 15 Sep…
46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…
A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…
68y · Female·Acute myocardial infarction and coronary artery atherosclerosis
A 68-year-old woman presented to St Vincent's Hospital emergency department with upper abdominal and left-sided chest pain following a stationary bicycle fall. Clinicians attributed her symptoms to codeine adverse reacti…
59y · Male·Hanging
Terry Grady, a 59-year-old man with a history of alcohol dependence, depression, and chronic pain, died by suicide in custody at Parklea Correctional Facility on 8-9 August 2019. He was bail-refused for domestic violence…
11y · Male·Sepsis
An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…
18y · Male·complications of acute on chronic subdural haemorrhage (operated) in the setting…
George Diamond, 18, died from acute-on-chronic subdural haemorrhage sustained during boxing sparring on 18 February 2019. He had suffered a head injury during sparring on 25 October 2018, presenting with headache, nausea…
Unknown·Sodium nitrite toxicity
Two deaths from sodium nitrite toxicity: Laurence Cox (63) and his daughter Ryley Cox (32). Laurence had a history of depression, anxiety, chronic pain, and medical conditions including emphysema and legal blindness, and…
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