19 results
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…
47y · Male·drowning
A 47-year-old man drowned in Lake Burbury while drift fishing alone at dusk in February 2022. He fell overboard when his boat struck a submerged object or ran aground in windy conditions, likely after the vessel suddenly…
87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …
Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…
0y · Male·positional asphyxia
Harvey McGlinn, a 3-week-old infant, died from positional asphyxia while being carried in a Boba Wrap fabric sling in an incorrect position on 8 April 2019. The sling was positioned horizontally and low across his mother…
25y · Male·Multiple organ failure due to acute paracetamol poisoning
Danny Whitton, a 25-year-old Aboriginal prisoner at Junee Correctional Centre, died from acute paracetamol toxicity causing multi-organ failure. He presented to the prison medical clinic on 5 November 2015 with vomiting …
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…
42y · Male·ligature compression of the neck (hanging)
Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental healt…
54y · Male·Ischaemic heart disease secondary to coronary artery atherosclerosis and aneurys…
Harry Barkas, a 54-year-old prisoner with longstanding type 2 diabetes, hypertension, and high cholesterol, collapsed in a prison bathroom. Autopsy revealed severe coronary artery atherosclerosis with dissecting aneurysm…
34y · Female·Complications of fall with fractured ankle and subsequent deep venous thrombosis…
Anna Bowditch, aged 34, died from complications of deep venous thrombosis (DVT) with pulmonary embolism and paradoxical stroke following elective fracture repair surgery. She had multiple known DVT risk factors: immobili…
47y · Male·Multi organ failure and sepsis complicating ulcerating colitis and intestinal ob…
David Waymouth, a 47-year-old prisoner with extensive medical comorbidities including hepatitis C, obesity, chronic pain requiring methadone, and depression, fell from his bed in prison and sustained a right hip fracture…
47y · Female·unascertained - natural causes
Leonie Margaret Philpott, a 47-year-old bush regeneration worker, was found deceased in bed on Christmas Day 2014. Despite a thorough three-cavity autopsy and comprehensive investigations including microscopic tissue exa…
75y · Female·Abdominal infection following surgery (repair of recurrent umbilical hernia) - s…
Wilma Ray Jones, 75, died of abdominal infection and sepsis following uncomplicated umbilical hernia repair. Post-mortem revealed ischaemic bowel with infarction, likely caused by superior mesenteric artery occlusion tri…
45y · Male·exsanguination due to incised wound to neck
Lawrence McCarty, a 45-year-old man in custody on remand, died by suicide in prison on 30 April 2011 by slashing his neck with a dismantled razor blade. Clinical lessons include: (1) reception staff failed to adequately …
93y · Male·Intracranial haemorrhage in the setting of over-warfarinisation
A 93-year-old man on warfarin for atrial fibrillation sustained a head strike in a fall at residential aged care. Initial assessment by ambulance was appropriate and he was not transferred. Over subsequent days, neurolog…
Female·early bronchopneumonia complicating combined drug toxicity (fentanyl overdose)
Wendy Osborne, a woman with a history of substance abuse and psychiatric issues, died from bronchopneumonia complicating fentanyl overdose. Her GP prescribed fentanyl patches (50mcg/h, increased to 75mcg/h) after one wee…
17y · Female·Acute Lymphocytic Meningitis and Focal Myocarditis
Amy Lee Dawkins, 17, presented twice to Rockingham General Hospital ED within two weeks with severe headaches, myalgias, and vomiting. On 28 December 2008, she was discharged with a diagnosis of viral upper respiratory t…
24y · Male·Combined drug toxicity (morphine and diazepam)
James, aged 24, died from combined drug toxicity (morphine and diazepam) following intentional overdose. He had engaged in prescription shopping across 19 doctors and 32 pharmacies over three years, obtaining large quant…
35y · Male·Acute Staphylococcus aureus Meningitis
Christopher Nigel Spinks, a 35-year-old tree surgeon, died of acute Staphylococcus aureus meningitis on 3 December 2002. He initially presented on 27 November 2002 with neck pain following a windsurfing accident. Dr R. n…
12y · Female·raised intracranial pressure due to ventriculo-peritoneal shunt blockage
A 12-year-old girl with congenital hydrocephalus and a ventriculo-peritoneal shunt presented to the ED with severe unrelieved headache after head trauma. An inexperienced junior doctor (6 weeks in role, minimal neurosurg…
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