240 results
31y · Male·Pulmonary thromboembolism arising from deep vein thrombosis
Adam David McKay, a 31-year-old geologist, died from pulmonary thromboembolism arising from deep vein thrombosis on 23 January 2003. He had recently completed extensive long-haul flights to West Africa and returned on 13…
39y · Male·Ligature compression of the neck (hanging)
Hendrik Jan Groothedde, a 39-year-old remand prisoner at Hakea Prison, died by ligature compression of the neck (hanging) on 31 January 2003. He had been admitted to custody in December 2002 following stabbing an ex-girl…
31y · Male·Lymphocytic Myocarditis in association with Acute Pericarditis (viral origin, ae…
Norman John Morgan, aged 31, died at Carnarvon Airport on 21 December 2001 from lymphocytic myocarditis with acute pericarditis (viral origin). He presented to Carnarvon Regional Hospital on 20 December with chest and sh…
44y · Male·cardiac arrhythmia in a man with liver failure due to cirrhosis and focal corona…
Michael John Herrick, a 44-year-old prisoner with end-stage liver cirrhosis secondary to hepatitis C and alcohol abuse, died from cardiac arrhythmia at Sir Charles Gairdner Hospital. He had been receiving aggressive trea…
46y · Female·pulmonary thromboembolism due to bilateral deep calf vein thrombosis
A 46-year-old woman with schizo-affective disorder died from pulmonary thromboembolism secondary to bilateral deep vein thrombosis five days after involuntary psychiatric admission. She was severely withdrawn, refusing f…
37y · Male·Acute Aspiration Pneumonitis following on Quetiapine Ingestion
Paul John Long, a 37-year-old man with chronic schizoaffective disorder and alcohol dependence, died on 4 November 2002 from acute aspiration pneumonitis following quetiapine overdose. After presenting to Avro Clinic in …
43y · Female·unknown
Rita Anderson, a 43-year-old Aboriginal woman with chronic alcohol-related organic brain damage, was admitted to Royal Darwin Hospital in March 2002 for stabilization and placement planning. Unable to safely live indepen…
67y · Male·acute renal failure with associated severe acidosis and hyperkalemia
A 67-year-old Aboriginal male with dementia was discharged from Royal Darwin Hospital on 4 November 2001 following cystoscopy and bladder neck incision for suspected obstruction. Critical communication failures meant the…
36y · Male·Acute on Chronic Myocardial Infarction
Mark Anselo Ugle, a 36-year-old Aboriginal man with a significant history of cardiac problems, seizures, and non-compliance with medication, died in East Perth Lockup on 9 December 2000 from acute on chronic myocardial i…
72y · Female·haemorrhage from penetrating duodenal ulcer
A 72-year-old woman collapsed at home and was admitted with black bowel motions (melaena) suggestive of gastrointestinal bleeding. This crucial history was documented by the ED doctor but not properly acted upon by the a…
48y · Female·Cardiorespiratory arrest due to cardiac tamponade as a result of perforation of …
Cheryl Hoggins, aged 48, died on 1 July 2000 from cardiac tamponade following perforation of the right atrium during central venous catheter exchange in ICU. She was recovering from emergency liver transplantation compli…
77y · Male·bilateral pulmonary emboli complicating deep vein thrombosis (left calf)
A 77-year-old man with dementia died from bilateral pulmonary emboli complicating deep vein thrombosis of the left calf. He was hospitalised for dehydration and diabetes management, then returned to psychiatric care. On …
74y · Male·disseminated carcinoma (widespread cancer); specifically haemorrhage into right …
Ronald Smallwood, a 74-year-old man with chronic paranoid schizophrenia and renal cancer, died in hospital from disseminated carcinoma. The key clinical lesson relates to institutional knowledge rather than direct patien…
58y · Male·hanging
A 58-year-old man remanded in custody awaiting trial died by hanging in prison. He had a history of depression treated with fluoxetine and was assessed by a forensic psychiatrist who found no evidence of depression or su…
34y · Male·aspiration pneumonia following seizure with concomitant global severe anoxic enc…
Kenneth Strangways, a 34-year-old Aboriginal man with post-traumatic epilepsy, organic brain damage from head injuries, alcoholism and psychiatric illness, died from aspiration pneumonia following a seizure. The death wa…
33y · Male·Postural asphyxia due to restraint (Posey Poncho vest)
A 33-year-old male admitted after drug overdose died from asphyxiation while restrained in a Posey Poncho vest. Successfully treated for overdose complications, he developed drug-induced delirium with agitation, promptin…
87y · Male·acute renal failure and two major haemorrhagic strokes
An 87-year-old man with multiple comorbidities including previous strokes, atrial fibrillation, and diabetes died from acute renal failure and two major haemorrhagic strokes after three months in an aged care facility. D…
66y · Male·Complications of chronic lithium therapy
Sydney Kennedy, a 66-year-old man with intellectual disability and bipolar affective disorder, died from complications of chronic lithium therapy. He had been on lithium for years with annual psychiatric review, but ther…
54y · Male·Unknown - death established on balance of probabilities but manner and cause und…
A 54-year-old man with major depressive disorder, chronic suicidality, and alcohol abuse was discharged from psychiatric hospital on 23 April 2014 while remaining at "very high chronic suicide risk." He had multiple prio…
45y · Male·Coronary Atherosclerosis
David Grieve, a 45-year-old man with chronic schizophrenia and multiple cardiac risk factors (hypertension, diabetes, obesity, smoking), died of coronary atherosclerosis while an involuntary psychiatric patient at Grayla…
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