121 results
77y · Female·Complications following a recent fracture and surgical repair of the right hip i…
A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Ke…
57y · Male·Coronary atherosclerosis
David Samuel Morris, aged 57, died from coronary atherosclerosis while in custody at Woodford Correctional Centre on 19 November 2011. He had a significant cardiac history including dilated cardiomyopathy, atrial fibrill…
38y · Male·Unascertained
Mr Aaron Oakley, 38 years old, died after entering the water while kayaking on Lake Hindmarsh on 10 July 2011. His remains were discovered in February 2012. The coroner found the death was unascertained. While evidence s…
68y · Male·Dilated cardiomyopathy with previous aortic valve replacement and aortic graft
A 68-year-old man with aortic valve replacement died from undiagnosed dilated cardiomyopathy, with retroperitoneal haemorrhage as a contributing factor. He developed a large perinephric haematoma (1900mL) secondary to ov…
34y · Male·Acute intracranial haemorrhage, malignant hypertension, renal artery stenosis
A 34-year-old man with malignant hypertension, prosthetic mitral valve, and renal artery stenosis died from acute intracranial haemorrhage while in prison custody. He presented with headache and hypertension on 13 June, …
93y · Male·Intracranial haemorrhage in the setting of over-warfarinisation
A 93-year-old man on warfarin for atrial fibrillation sustained a head strike in a fall at residential aged care. Initial assessment by ambulance was appropriate and he was not transferred. Over subsequent days, neurolog…
46y · Female·Complications following cardiorespiratory arrest in association with an air embo…
A 46-year-old woman died from air embolism during a gastroscopy to manage complications from bariatric surgery. The initial laparoscopic sleeve gastrectomy on 9 November 2007 had a staple misfire that was inadequately re…
41y · Male·Cardiomyopathy in a setting of acute abdomen
Rodney David Keegan, a 41-year-old man with intellectual disability, epilepsy, psychosis, and prior cardiac surgery, was admitted to hospital following a fall. He developed acute abdominal pain with free fluid on imaging…
31y · Male·Acute colonic pseudo-obstruction; death certificate amended to 'unascertained' -…
Cameron Yeates, a 31-year-old man with intellectual disability (IQ 64) and longstanding gastrointestinal issues, died from acute colonic pseudo-obstruction with underlying malnourishment. Key clinical lessons: (1) severe…
43y · Female·Acute thrombosis of a prosthetic mitral valve
A 43-year-old woman with prosthetic mitral and aortic valves due to rheumatic heart disease died from acute thrombosis of her prosthetic mitral valve following cessation and recommencement of warfarin for IVF treatment. …
64y · Male·Acute anterior myocardial infarction and coronary artery occlusion
Leon James Thompson, a 64-year-old man with significant cardiac history including a recent myocardial infarction in December 2010, died from acute anterior myocardial infarction with coronary artery occlusion while resid…
38y · Female·Pulmonary Thromboembolism
Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…
86y · Male·head injury (acute intracerebral haemorrhage and subarachnoid haemorrhage)
An 86-year-old man with recurrent falls history was admitted to hospital after a fall at home. He was initially assessed as low falls risk (11/20 on FRAT) but then reassessed as medium risk. Despite falls interventions i…
62y · Male·Injuries sustained as a result of an aviation accident
Six people, including pilot Kerry Endicott and passenger Robert Harold Henderson, died in an aviation accident on 28 July 2004 when a Piper Cheyenne aircraft collided with terrain near Myrrhee, Victoria. The pilot was hi…
37y · Male·injuries sustained as a result of aviation accident
A Piper Cheyenne aircraft (VH-TNP) carrying six people crashed near Benalla, Victoria on 28 July 2004. The pilot, Kerry Endicott (aged 69), was highly experienced with over 14,000 flight hours. During instrument meteorol…
34y · Female·Injuries sustained as a result of aviation accident (collision with terrain)
On 28 July 2004, Belinda Anne Andrews, aged 34, died along with five others when Piper PA-31T aircraft VH-TNP collided with terrain near Benalla, Victoria during a GPS approach in instrument meteorological conditions. Th…
33y · Female·Injuries sustained as a result of aviation accident—specifically, controlled fli…
A Piper PA-31T Cheyenne aircraft collided with terrain near Benalla, Victoria on 28 July 2004, killing all six occupants including pilot Kerry Endicott and passenger Jacqueline Henderson. The pilot was highly experienced…
69y · Male·Injuries sustained as a result of aviation accident - controlled flight into ter…
A Piper PA-31T Cheyenne aircraft carrying six occupants crashed into terrain near Benalla, Victoria on 28 July 2004 while conducting a GPS approach in instrument meteorological conditions. The pilot, Kerry Endicott, was …
82y · Male·closed head injury (subdural haematoma) sustained in a fall
An 82-year-old man on warfarin died from a subdural haematoma sustained in a fall at a rehabilitation centre. He fell while attempting to walk to the toilet unassisted after not being provided with a urinal bottle, despi…
81y · Male·Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with co…
An 81-year-old man died from retropubic and retroperitoneal haemorrhage complicating pelvic fractures sustained in a fall at church. He was on warfarin for atrial fibrillation with an excessive INR of 4.6 at the time of …
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