59 results
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
77y · Female·Pneumonia with contributing factors of acquired brain injury, Parkinson's diseas…
A 77-year-old woman with acquired brain injury, Parkinson's disease, epilepsy and intellectual disability died of pneumonia while an SDA resident. She presented with breakthrough seizures and aspiration pneumonitis on 16…
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…
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
68y · Male·Pneumonia on a background of interstitial lung disease
Stephen Lunson, a 68-year-old man with intellectual disability, epilepsy, and interstitial lung disease, died from pneumonia. He had been under medical review for progressive respiratory symptoms since 2019. In early Dec…
79y · Male·Pneumonia, due to or as a consequence of emphysema (chronic obstructive pulmonar…
Herbert Charles Hilsley, aged 79, died of pneumonia secondary to emphysema with contributing ischaemic heart disease while incarcerated at Rockhampton Base Hospital. He had extensive comorbidities including COPD, ischaem…
53y · Male·Neck compression in the circumstances of hanging
A 53-year-old man with sudden-onset major depression died by hanging after being discharged from acute mental health crisis services. He presented with depressive symptoms, suicidal ideation with vague plans, and failed …
64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…
Wayne Mullin, a 64-year-old man with severe eosinophilic asthma, bronchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 September and 20 October 2021. Toxicology revealed oxycodone and diazepam at l…
73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…
A 73-year-old man presented to ED with acute facial droop and speech difficulty on 5 September 2020. He was misdiagnosed with Bell's palsy despite clinical features suggestive of stroke. A non-contrast CT brain (inadequa…
1y · Male·Chronic Bronchial Asthma
Master T, a 17-month-old boy with chronic asthma, died from status asthmaticus on 25 November 2019. He had experienced recurrent wheezing episodes requiring multiple hospital admissions in September-October 2019. Medical…
13y · Male·Asthma
Master S was a 13-year-old Aboriginal boy with severe persistent asthma who died at home on 13 November 2019. He was found unresponsive with his nebuliser mask on his face. The coroner accepted that death resulted from a…
75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…
Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…
56y · Male·acute exacerbation of chronic obstructive pulmonary disease (bronchial asthma) i…
Ashley Adrian Lane, a 56-year-old Aboriginal man from the Ngaanyatjarra Lands, died in custody at Kalgoorlie Regional Hospital from acute exacerbation of chronic obstructive pulmonary disease (asthma). He was a remand pr…
51y · Female·Mixed drug toxicity
A 51-year-old woman with longstanding treatment-resistant depression, chronic pain, and suicidal ideation died from mixed drug toxicity. She intentionally overdosed on multiple medications including benzodiazepines, anti…
42y · Male·hanging
A 42-year-old prisoner with generalised anxiety disorder and chronic tinnitus causing significant distress died by suicide while incarcerated. In the months preceding his death, he presented repeatedly to health staff re…
76y · Male·Sepsis, with osteomyelitis and infective endocarditis
Alex Mills, a 76-year-old sentenced prisoner with complex medical history including atrial fibrillation, valvular heart disease, and rheumatoid arthritis, died from sepsis caused by osteomyelitis and infective endocardit…
8y · Male·acute exacerbation of chronic asthma
An 8-year-old boy with undertreated chronic asthma presented to North West Regional Hospital with acute exacerbation. Initial assessment underestimated severity. Despite initial improvement with salbutamol, ipratropium a…
40y · Female·Cerebral oedema of unknown aetiology with probable contribution from Hashimoto's…
Sarah Louise Rose, aged 40, died from cerebral oedema of unknown aetiology with probable contribution from Hashimoto's encephalopathy. She had been diagnosed with Hashimoto's thyroiditis in late 2011 and prescribed thyro…
63y · Male·respiratory failure in a man with lung cancer, chronic obstructive pulmonary dis…
Stephen Craig Solly, aged 63, died from respiratory failure due to advanced lung cancer, COPD, and pulmonary fibrosis while an involuntary psychiatric patient at Graylands Hospital. He had paranoid schizophrenia, cogniti…
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…
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