93y · Female·acute right lower limb ischaemia
Adelina Zito, a 93-year-old resident of an aged care facility, died from acute limb ischaemia after a 6-7 day delay in escalating her care. She developed right leg pain around 26-28 July 2022 that worsened despite parace…
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…
43y · Male·compression of the neck in keeping with hanging
A 43-year-old man on home detention died by hanging in September 2021. He had a history of epilepsy, depression, anxiety, illicit drug use, and previous suicide attempts. In the weeks before death, he presented to hospit…
48y · Male·Complications of human immunodeficiency virus infection with terminal palliative…
Travis Baumgarten, a 48-year-old Aboriginal man with HIV diagnosed in 1994, died from complications of HIV while serving a prison sentence at Acacia Prison. He progressively refused antiretroviral therapy and medical tre…
45y · Male·atherosclerotic heart disease
Lex Gregory Maher, a 45-year-old Aboriginal man imprisoned at Greenough Regional Prison, died of atherosclerotic heart disease while playing basketball. He had abnormal ECGs detected in March and May 2022 and was appropr…
48y · Male·unascertained
Daniel Harvey, a 48-year-old man with morbid obesity, cirrhosis, diabetes, and polysubstance use including methadone and methamphetamine, was found unresponsive in immigration detention on 10 August 2020. He had complain…
59y · Male·hanging
A 59-year-old man with major depression and psychotic features was lawfully detained under an inpatient treatment order at Noarlunga Hospital's Morier Ward. He was appropriately managed, initially in the high-dependency …
55y · Female·Multiple injuries sustained in a train incident
Andrea Milner, a 55-year-old woman with cerebral palsy, depression, and anxiety, died from multiple injuries sustained when she drove her motorised wheelchair off a railway platform onto tracks at Ormond station on 23 Se…
73y · Male·Complications of multiple injuries sustained in a motor vehicle incident (car vs…
A 73-year-old man with extensive medical comorbidities including severe biventricular heart failure, COPD, sleep apnoea, and hypertension experienced a medical episode while driving, causing him to cross into oncoming tr…
84y · Male·Ischaemic heart disease and coronary artery atherosclerosis in the setting of ty…
Jonathan Uphill, an 84-year-old man with extensive comorbidities including type 2 diabetes, hypertension, and prior cardiac risk factors, died of ischaemic heart disease with coronary artery atherosclerosis. He underwent…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…
37y · Female·sepsis due to necrotising fasciitis following abdominoplasty with liposuction
A 37-year-old woman died from sepsis due to necrotising fasciitis following abdominoplasty and liposuction. She was discharged on post-operative day 4 with severe pain, nausea, and vomiting, which were attributed to norm…
17y · Male·Gunshot wound to the head
Dustin Buckley, 17, died from a gunshot wound to the head at Royal Melbourne Hospital on 27 August 2017. The incident occurred during target shooting at Cat Track when KD fired a .22 rifle that discharged, striking Dusti…
89y · Male·Cervical spine trauma
Robert Driver, 89, died from cervical spine trauma sustained after being struck by another dementia-affected resident in an aged care facility. He was assessed overnight at the facility and transferred to hospital the fo…
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…
54y · Female·neck compression secondary to hanging
Ms NXA, a 54-year-old woman with complex mental health conditions including depression, CPTSD, and anxiety, presented to hospital after a suicide attempt by overdose on 9 August 2021. She was experiencing severe tinnitus…
50y · Male·ligature compression of the neck (hanging)
Matthew Francis Leach, a 50-year-old man with longstanding alcohol dependence, depression, and a history of suicide attempts, died by ligature hanging in his cell at Hakea Prison shortly after being sentenced to 12 month…
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
20y · Male·gunshot wound to the chest
A 20-year-old man with borderline personality disorder, who had made over 25 suicide attempts in the two years prior, died from a gunshot wound sustained during a police encounter. He had called mental health services an…
35y · Male·multi-drug toxicity
CPL Ian Turner, a 35-year-old Special Forces soldier with combat-related PTSD, died from multi-drug toxicity in July 2017. His death followed multiple deployments to Afghanistan and Iraq, domestic violence incidents, dis…
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