20 results
Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…
This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…
3y · Male·Disseminated Staphylococcus aureus infection
A 3-year-old Aboriginal boy died from disseminated Staphylococcus aureus infection with sepsis. He presented to a remote clinic on 10 April with fever and dizziness, then returned on 13 April with irregular fever, lethar…
<1y · Male·Hypoxic ischaemic encephalopathy complicating peri partum asphyxia
A term neonate died at 3 days of age from hypoxic ischaemic encephalopathy due to perinatal asphyxia. The mother presented in early labour, was initially discharged, then readmitted when labour progressed. Labour progres…
28y · Male·MRSA sepsis
Mahmoud Allam, a 28-year-old man, died from MRSA sepsis whilst in custody at Parklea Correctional Centre. He initially presented with upper respiratory symptoms on 11 June 2016, followed by increasing symptoms including …
67y · Male·Gas gangrene with antecedent cause of Clostridium septicum septicaemia
Peter Smith, 67, presented to Cooma Hospital with severe leg muscle cramps and pain on 6 February 2018. Despite appropriate pain management and initial investigation suggesting rhabdomyolysis, he rapidly deteriorated and…
35y · Male·Active rheumatic pancarditis complicated by pulmonary arterial hypertension, pne…
A 35-year-old Aboriginal man died from rheumatic pancarditis complicated by pulmonary hypertension, pneumonia and unspecified connective tissue disease. He had presented repeatedly to Katherine Hospital with symptoms sug…
5y · Male·Acute bronchopneumonia and diffuse alveolar damage due to acute rheumatic cardit…
A 5-year-old boy with rheumatic heart disease and acute mitral valve regurgitation presented to Mt Isa Hospital with acute heart failure. Although initially recognised as deteriorating by the paediatrician on-call, the s…
6y · Male·pneumonia complicating influenza A (H1N1) infection with secondary streptococcal…
Sebastian Parman, a 6-year-old boy, died from pneumonia complicating influenza H1N1 with secondary group A streptococcal infection causing scarlet fever, empyema and sepsis. Multiple clinical failures contributed: an inf…
50y · Male·acute myocardial infarction due to coronary atherosclerosis
Allen Burke, a 50-year-old Aboriginal man in custody, died from acute myocardial infarction due to severe coronary atherosclerosis. On the morning of his death, he reported headache, vomiting, and sore throat. Nurse asse…
93y · Male·Complications following colectomy for Clostridium difficile pancolitis in the se…
A 93-year-old man with a history of antibiotic use for a neck abscess developed diarrhoea during hospitalisation. Despite testing negative for Clostridium difficile at St Vincent's Hospital, he was transferred to a rural…
52y · Male·Acute coronary syndrome caused by coronary artery embolus secondary to infective…
Mark Proberts, a 52-year-old man with multiple chronic conditions (diabetes, liver disease, hypertension), died in hospital from acute coronary syndrome secondary to infective endocarditis. He was transferred from correc…
74y · Female·Cardio-renal failure due to gangrene of calculous gallbladder, with significant …
An elderly woman with a documented penicillin allergy, wearing a MedicAlert bracelet, presented to emergency with respiratory distress and chest pain. She was administered intravenous Ampicillin without allergy verificat…
83y · Male·Aspiration pneumonia
An 83-year-old man with stroke, dementia, dysphagia, and multiple comorbidities developed aspiration pneumonia while in aged care. On 1 May 2008, he presented with acute swallowing difficulty and was examined by his GP w…
<1y · Female·respiratory failure due to congenital pneumonia with hyaline membrane disease ca…
Trinity Kison, a 21-hour-old neonate born at 35 weeks gestation, died from respiratory failure due to congenial pneumonia caused by streptococcus pneumoniae. The maternal high vaginal swab taken one week before delivery …
<1y · Female·Perinatal asphyxia
Summer Elizabeth Rose Niehoff died from perinatal asphyxia hours after vaginal birth following a prolonged labour in hospital. The coroner found multiple clinically preventable failures: escalation of oxytocin augmentati…
17y · Male·fatal asphyxia resulting from severe upper airway obstruction secondary to acute…
Kieran Watmore, a fit 17-year-old male, died from fatal asphyxia at Albany Regional Hospital on 28 August 2008 while being treated for acute tonsillitis. He presented to ED on 27 August with severe throat pain and was pr…
29y · Female·respiratory depression caused by morphine intoxication on a background of upper …
A 29-year-old woman with infectious mononucleosis and severe sore throat died from respiratory depression caused by morphine intoxication with concurrent upper airway narrowing. A GP administered 30mg intramuscular morph…
46y · Male·Upper airway obstruction due to acute tonsillitis with laryngeal oedema and haem…
A 46-year-old man with acute tonsillitis complicated by upper airway obstruction died at Cunderdin District Hospital. He presented with severe pharyngitis on 5 September 2002, was admitted to Kellerberrin Memorial Hospit…
<1y · Male·cardiogenic shock and neonatal encephalopathy
Matthew Hutchinson, born at 1 day of age at Flinders Medical Centre, died from cardiogenic shock and neonatal encephalopathy. While obstetric care was appropriate, neonatal care was significantly deficient. Critical fail…
33y · Male·lobar pneumonia (Streptococcus pneumonia with septic shock)
Owen King, a 33-year-old Aboriginal man, died of lobar pneumonia on 24 June 2002 at Alice Springs Hospital following brief police custody for alleged intoxication. He was apprehended twice on 23 June under protective cus…
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