146 results
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…
84y · Male·acute aspiration complicating periprosthetic fractured right femur (operated) on…
Bryan Roocroft, 84 years old with severe dementia, suffered a periprosthetic right femur fracture after two falls at aged care on 24 December 2020 while on oxazepam. He underwent surgical repair on 25 December and was pl…
51y · Male·Hyperthermia of unknown cause in a man with cardiac hypertrophy; chronic obstruc…
Arthur Andrianakis, 51, died from hyperthermia of unknown cause with cardiac hypertrophy and COPD. He presented to hospital with respiratory distress following police custody for assaulting his mother. Initial diagnosis …
6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…
Austin Facer, a 6-year-old boy, suffered multiple cardiac arrests at school on 21 October 2019, initially resuscitated successfully, but died during transfer preparation to a higher-level hospital that evening. Autopsy r…
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…
21y · Male·Hypoxic brain injury arising from severe anaphylactic shock due to administratio…
Lucas Peyret, a 21-year-old with no significant medical history, presented to hospital with acute appendicitis and underwent emergency laparoscopic appendicectomy. Surgery was routine and uneventful. Upon emergence from …
72y · Male·Diffuse large B cell lymphoma
Douglas Stott, a 72-year-old prisoner with diffuse large B cell lymphoma, died of natural causes in hospital on 7 January 2021. He had been receiving telehealth oncology consultations while incarcerated but refused in-pe…
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…
68y · Male·Aspiration pneumonia (due to cerebral palsy and dysphagia)
Dana John Walter, 68, died of aspiration pneumonia following cerebral palsy and severe dysphagia. He was readmitted to hospital on 11 August 2020 with acute respiratory distress three days after discharge. Despite thicke…
68y · Female·Cardiomyopathy with atrial fibrillation, pulmonary hypertension, and alcohol int…
Margaret Brown, a 68-year-old woman with significant cardiac disease (cardiomyopathy, atrial fibrillation, pulmonary hypertension) and chronic alcohol abuse, died at home from cardiomyopathy with alcohol intoxication as …
70y · Male·advanced left frontal glioblastoma (operated)
A 70-year-old male prisoner died from advanced left frontal glioblastoma. The tumour was identified when he presented with acute stroke-like symptoms (facial droop, weakness, confusion) in July 2018 while imprisoned. He …
40y · Male·Bronchial Asthma
Ricardo Arquero, a 40-year-old man serving a prison sentence, died from acute bronchial asthma at Glen Innes Correctional Centre on 19 August 2019. He had a documented history of asthma since childhood and was provided w…
1y · Female·unrecognised oesophageal intubation
A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of pe…
46y · Male·Hypoxic ischaemic brain injury complicating a cardiac arrest during anaesthetic …
A 46-year-old male underwent elective inguinal hernia repair at a private hospital. During anaesthetic induction, he experienced cardiac arrest. The endotracheal tube (ETT) was visualized passing through the vocal cords,…
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…
72y · Female·Pneumonia as a consequence of chronic obstructive airway disease
Ms Vigor-Newitt, a 72-year-old woman in prison, died from pneumonia complicated by chronic obstructive airway disease. She had presented with respiratory symptoms on 27 and 29 September 2020 and was appropriately hospita…
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…
74y · Male·Acute exacerbation of chronic airways disease, with carcinoma of prostate being …
William Berger, a 74-year-old man serving a life sentence for murder, died from acute exacerbation of chronic obstructive pulmonary disease (COPD) with metastatic prostate cancer as a significant contributing condition. …
36y · Male·bronchial asthma
Nathan Reynolds, a 36-year-old Aboriginal man with severe asthma, died from bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease man…
48y · Male·Coronary atherosclerosis with acute cardiac event
Richard William Hobbs, aged 48, died from cardiac arrest in custody at Brisbane Correctional Centre on 21 November 2017. He had significant comorbidities including coronary artery disease (recent stent insertion), diabet…
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