29 results
57y · Male·Aspiration pneumonia in a man with cerebral palsy, intellectual disability and L…
A 57-year-old man with cerebral palsy, intellectual disability, and Lennox-Gastaut syndrome died from aspiration pneumonia following a short hospital admission. He had a history of recurrent aspiration pneumonia and was …
65y · Male·Aspiration pneumonia complicating urosepsis in setting of nephrolithiasis and ce…
Shane Michael Kelly, a 65-year-old man with cerebral palsy living in specialist disability accommodation, died from aspiration pneumonia complicating urosepsis secondary to nephrolithiasis. He was admitted to hospital on…
94y · Female·Complications of a fractured neck of femur sustained in an unwitnessed in-hospit…
A 94-year-old woman with significant cardiopulmonary comorbidities died from complications of a fractured femur sustained in an unwitnessed hospital fall. Despite identification as high falls risk and implementation of f…
44y · Male·Complications following seizure on a background of acquired epilepsy; acquired b…
Anthony Dzaja, aged 44, died from complications of seizures secondary to acquired brain injury sustained in a 1997 motor vehicle accident. He had progressively deteriorated over several years with worsening epilepsy, cog…
46y · Male·Aspiration pneumonia complicating epistaxis in the setting of prolonged nasal pr…
Hau Bui Nguyen, a 46-year-old man with severe acquired brain injury, dysphagia, and recurrent aspiration pneumonia, died from aspiration pneumonia complicating epistaxis following prolonged nasal prong oxygen therapy. Du…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
75y · Male·Complications of multiple cardiac and respiratory comorbidities
A 75-year-old man with multiple cardiac and respiratory comorbidities died in prison from complications of his underlying conditions. He had pulmonary arterial hypertension, right ventricular failure, chronic lung diseas…
59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma
Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite M…
58y · Male·Pneumonia and urosepsis
Brent Newman, a 58-year-old man with Down syndrome and early-onset dementia, died from pneumonia and urosepsis following inadequate care at an aged care facility. His indwelling catheter was poorly managed, causing ureth…
64y · Male·Pneumonia in a man with Lennox-Gastaut syndrome
Raymond Dempster, a 64-year-old man with severe Lennox-Gastaut syndrome and dysphagia, died of pneumonia following aspiration. He had experienced recurrent aspiration pneumonia episodes over several years. Critical clini…
89y · Male·combined effects of cerebrovascular accident, pneumonia and chronic cardiac fail…
An 89-year-old man with multiple comorbidities (ischaemic heart disease, diabetes, COPD) presented with chest infection and was admitted for heart failure. He suffered an acute stroke with subsequent delirium and combati…
78y · Male·cardiorespiratory failure due to complications of tracheal stenosis
Bruce Hodges, a 78-year-old man with a 20-year-old tracheostomy following laryngeal cancer surgery, presented to hospital with progressive shortness of breath and tracheal stenosis. Over 48 hours of admission, his respir…
18y · Male·Incised wound to right axilla with complete transection of basilic vein, brachia…
Thomas Redman, aged 18, sustained a catastrophic laceration to his right axilla involving complete transection of major arteries and veins after putting his arm through a glass window at a rural property near Gloucester,…
7y · Male·cardiorespiratory failure in a child with cerebral palsy and epilepsy, with acut…
Child KT (Vinnie), age 7, died of cardiorespiratory failure from cerebral palsy and epilepsy after a prolonged hospital admission. He had complex medical needs including chronic respiratory disease, requiring PEG feeding…
18y · Male·acute asthma
Omar Jamil Moujalled, 18 years old, died from acute asthma during the unprecedented thunderstorm asthma event in Melbourne on 21 November 2016. He had pre-existing asthma and severe hay fever with exceptionally high sens…
81y · Female·Aspiration pneumonia
An 81-year-old woman with intellectual disability, cerebral palsy and dysphagia died from aspiration pneumonia. She resided in DHHS care with appropriate preventative measures in place including softened diet and thicken…
69y · Male·metastatic squamous cell carcinoma of the lung with chronic obstructive lung dis…
Barry John Matthews, aged 69, died of metastatic squamous cell carcinoma of the lung with chronic obstructive lung disease at an aged care facility while subject to a section 32 detention order. He had undergone chemothe…
72y · Male·Bilateral pneumothoraces and pneumoperitoneum due to insufflation of the bladder…
Stephen Herczeg, a 72-year-old patient with COPD and urinary tract infection, died from bilateral pneumothoraces and pneumoperitoneum caused by insufflation of his bladder with oxygen. The oxygen supply tubing was someho…
68y · Female·Coronary heart disease
A 68-year-old woman with diabetes, hypertension, hypercholesterolaemia, COPD and chronic renal failure presented with chest pain and dyspnoea. She was admitted with suspected congestive cardiac failure; troponins were no…
35y · Male·bronchial asthma
A 35-year-old man with mild asthma died from severe bronchial asthma within hours of arriving at a Christmas Island immigration detention centre. He was initially identified as asthmatic at the jetty but not transferred …
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