17 results
53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis
An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …
85y · Female·Complications of a left ankle fracture (operated)
An 85-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, hypertension, prior stroke) sustained a left ankle fracture requiring surgical repair. A significant delay occurred in removing her pla…
64y · Male·Metastatic Non-Small Cell Lung Cancer
Philip Nguyen, aged 64, died from metastatic non-small cell lung cancer whilst in lawful custody in Long Bay Hospital on 10 May 2020. He had been diagnosed with advanced lung cancer in February 2019 after presenting with…
93y · Female·Catastrophic subdural haemorrhage resulting from head strike sustained in a witn…
Dayle Patricia Weldon, a 93-year-old woman with dementia, fell in the secure suite of an aged care facility and sustained a catastrophic subdural haemorrhage from which she died three days later. The coroner found that M…
76y · Male·Chest sepsis in a man with ischaemic heart disease
A 76-year-old man with multiple myeloma and complex medical history died from chest sepsis and myocardial infarction following a medication dispensing error. After discharge from hospital for spinal compression fractures…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
59y · Male·Carcinomatosis due to adenocarcinoma of the pancreas
Dennis Petzler, a 59-year-old prisoner, died from carcinomatosis due to adenocarcinoma of the pancreas with extensive metastatic spread. He presented with abdominal pain and nausea in June 2018, initially managed as gast…
42y · Male·Hypoxic ischaemic brain injury secondary to cardiac arrest caused by massive pul…
A 42-year-old man died from hypoxic ischaemic brain injury following cardiac arrest due to a massive pulmonary embolism. He sustained a tibial fracture in a motor vehicle accident and underwent external fixation. He deve…
58y · Male·carcinomatosis from unknown primary
David Kevin Loader, a 58-year-old life prisoner, died from metastatic cancer of unknown primary in January 2020. He presented with multiple episodes of back, abdominal, shoulder and rib pain between July and November 201…
61y · Female·multi organ failure due to abdominal sepsis
Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery requ…
61y · Male·Coronary atherosclerosis
Steven Harrison, aged 61, died of sudden coronary atherosclerosis while incarcerated at Wolston Correctional Centre. He had multiple cardiovascular risk factors including Type 2 diabetes, heavy smoking history, and intra…
89y · Male·Congestive heart failure due to or as a consequence of ischaemic cardiomyopathy
George Fenech, 89, died of ischaemic cardiomyopathy complicated by congestive heart failure after a fall at a nursing home. He suffered a cervical spine injury (C1-C2 subluxation) and head laceration during an unwitnesse…
54y · Male·incised wound to the neck
Terrence Michael Malone, a 54-year-old man with a 20-year history of bipolar affective disorder, PTSD, and alcohol dependence, died by suicide in Brisbane Correctional Centre on 8 November 2014, three days after re-incar…
88y · Female·Sepsis complicated by multiple organ failure in a woman with comorbidities in th…
An 88-year-old woman died from sepsis with multiple organ failure following shoulder surgery. She developed an undiagnosed urinary tract infection after placement of an indwelling catheter. Critical failures included: in…
62y · Male·Complications of Hepatocellular Carcinoma
A 62-year-old man with hepatitis C-related cirrhosis died from complications of hepatocellular carcinoma while in prison custody. He was identified with a 4cm liver mass in April 2016 and confirmed to have an 8cm hepatoc…
53y · Male·Self-inflicted gunshot wound to the head
Leslie Winbank, a 53-year-old man with chronic pain from disc prolapse and prostate cancer, died from a self-inflicted gunshot wound during a police siege at his home. He had a family relationship breakdown and was on pa…
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