119 results
86y · Male·ischaemic and hypertensive heart disease
An 86-year-old man died of ischaemic and hypertensive heart disease while serving a prison sentence. He had multiple comorbidities including atrial fibrillation, congestive cardiac failure, and cirrhosis. The coroner exa…
82y · Male·Complications of large bowel obstruction in a man with diverticular disease and …
An 82-year-old man died from complications of large bowel obstruction secondary to a sigmoid mass while incarcerated at Port Phillip Prison. He presented with abdominal pain and vomiting following a fall, and imaging con…
90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …
A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …
83y · Male·Congestive cardiac failure due to ischaemic and valvular heart disease, with her…
Frank Valentine, an 83-year-old man, died from congestive cardiac failure due to ischaemic and valvular heart disease, with hereditary haemorrhagic telangiectasia (HHT) and anaemia as contributory conditions. He was serv…
50y · Male·Upper cervical spine injury
A 50-year-old farmer died from an upper cervical spine injury sustained in a motor vehicle accident during an extreme weather event. While riding a quadbike to bring cattle in for afternoon milking during a severe storm …
48y · Female·intracerebral haemorrhage on a background of anticoagulation therapy for a recen…
Monique Jacinta Gomez, a 48-year-old woman with schizoaffective disorder and a mechanical aortic valve, died from intracerebral haemorrhage while receiving anticoagulation therapy for a recent embolic stroke. She was adm…
95y · Female·Acute intracranial haemorrhage
DRF, a 95-year-old woman with dementia, hearing impairment, mobility limitations, and mild cognitive impairment, died from acute intracranial haemorrhage following blunt head trauma. She had been living with her son UJN,…
83y · Female·Pulmonary thromboembolism due to aortic stenosis (recent transcatheter aortic va…
An 83-year-old woman with severe aortic stenosis, atrial fibrillation, and heart failure died from pulmonary embolism one day after discharge following transcatheter aortic valve replacement (TAVI). Clinical lessons cent…
98y · Female·Sepsis due to sacral pressure ulcer complicated by osteomyelitis against a backg…
A 98-year-old woman with dementia and multiple comorbidities died from sepsis secondary to a sacral pressure ulcer that progressed to osteomyelitis while in residential aged care. The coroner identified systemic clinical…
73y · Male·subdural haematoma from fall
Leonard Athol Long, a 73-year-old on warfarin for mechanical mitral valve replacement, fell twice during hospitalization for urinary tract infection. He was on SMZ-TMP antibiotics, which interact significantly with warfa…
49y · Male·Acute myocardial infarction complicating prosthetic valve thrombosis in a man wi…
Joshua Paul Coates, aged 49, died from acute myocardial infarction complicating prosthetic valve thrombosis following mechanical aortic valve replacement. Post-mortem examination revealed a large blood clot obstructing h…
76y · Male·pulmonary thromboembolism in the setting of deep vein thrombosis
A 76-year-old man with a history of unprovoked DVT/PE on lifelong warfarin was admitted with COVID-19 and developed a bleeding duodenal ulcer requiring endoscopic treatment. Warfarin was ceased to prevent further bleedin…
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…
87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …
Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…
72y · Male·cerebral malignancy (glioblastoma multiforme)
Geoffrey Adams, aged 72, died in custody from glioblastoma multiforme (cerebral malignancy). He presented with acute neurological symptoms (slurred speech, facial droop, weakness) on 13 November 2020 during a routine med…
89y · Male·Complications of cerebrovascular accident (stroke); specifically a catastrophic …
Hugh Ward, an 89-year-old sentenced prisoner, died from complications of stroke following an embolic cerebrovascular accident at Sir Charles Gairdner Hospital. While incarcerated, Mr Ward had multiple comorbidities inclu…
44y · Male·Unascertained; presumed exposure
Roly Nixon, a 44-year-old man with significant medical comorbidities including rheumatic heart disease, diabetes, organic psychosis and seizure disorder, disappeared from Fitzroy Crossing, Western Australia on 28 January…
33y · Male·Ventricular arrhythmia associated with cardiomegaly
Blake Edwards, a 33-year-old man with Tatton-Brown-Rahman syndrome and cardiomegaly, died suddenly from ventricular arrhythmia while in respite care. He became unresponsive approximately 30 minutes after being given yogh…
79y · Male·Iatrogenic right ventricular injury complicating drainage of pericardial collect…
A 79-year-old man died from iatrogenic right ventricular injury sustained during attempted drainage of a post-operative pericardial effusion following coronary artery bypass grafting. During a minimally invasive sub-xiph…
41y · Male·haemothorax due to ruptured thoracic aortic aneurysm in a man with Marfan syndro…
A 41-year-old man with Marfan syndrome and a thoracic aortic aneurysm managed conservatively with blood pressure medications died from aneurysm rupture while imprisoned. Methylamphetamine in his system significantly elev…
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