45 results
38y · Male·Sepsis complicating bronchopneumonia and chest wall abscess in the setting of an…
A 38-year-old man with secondary adrenal insufficiency from childhood chemoradiation died from sepsis complicating a chest wall abscess and bronchopneumonia, precipitated by an adrenal crisis. He presented to his GP with…
Female·Hanging
This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral…
61y · Female·multi organ failure due to abdominal sepsis
Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery requ…
29y · Male·cardiac arrhythmia
David Dungay, a 29-year-old Aboriginal man with chronic schizophrenia, type 1 diabetes, and obesity, died on 29 December 2015 in Long Bay Hospital's Mental Health Unit while in custody. The immediate trigger was his refu…
17y · Male·Diabetic ketoacidosis
Caleb Pearson, a 17-year-old with undiagnosed Type 1 diabetes, presented with pharyngitis and was diagnosed and treated for a throat infection by his GP on 25 May 2015. Over the following two days he deteriorated with vo…
33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…
Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraem…
31y · Female·incised wounds to the neck and arms
A 31-year-old illustrator with a recent onset of acute depression and suicidal ideation attended Fremantle Hospital ED via ambulance after GP referral on 12 May 2014. She had made a suicide attempt at a beach two days ea…
49y · Female·Widespread small and large bowel, splenic and hepatic infarction secondary to se…
Susan Bourke, a 49-year-old woman, died from widespread small and large bowel infarction secondary to severe aortic atherosclerosis causing critical stenosis of the superior mesenteric and coeliac arteries. She presented…
66y · Male·unascertained
A 66-year-old man with insulin-dependent diabetes mellitus and severe hypoglycaemia unawareness died on 20 June 2013, the day after commencing a Medtronic Paradigm insulin pump. He was found collapsed at home after plann…
33y · Male·presumed fatal cardiac arrhythmia in the presence of coronary artery atheroscler…
Dr D., a 33-year-old physicist, was admitted to Hornsby Hospital on 27 December 2012 with abdominal pain, nausea, vomiting and joint pain. His presentation included hypotension (97/61), tachycardia (116/min), hyponatraem…
63y · Male·Hypotensive and atherosclerotic heart disease
A 63-year-old male prisoner with Type II diabetes, hypertension, obesity and coronary atherosclerosis died of cardiac arrhythmia while engaged in farm work at a minimum-security prison. Dr L. provided acceptable diabetes…
86y · Male·Septic shock secondary to urosepsis
Robert Avery, 86, was admitted to Valley Private Hospital for colonoscopy to investigate constipation. After the procedure was cancelled due to respiratory concerns, he was managed with fluid restriction, bowel preparati…
5y · Male·unascertained
A 5-year-old boy and his sister (3 years old) and mother were killed by their father between 28-29 April 2012 in their Glen Waverley home. The father, who had experienced cognitive impairment and mood changes following a…
36y · Male·Hanging (Mr Sharma); Homicide by smothering/suffocation or chloroform exposure (…
Nilesh Sharma, a 36-year-old Fiji Indian man, killed his wife Preetika, son Divesh (5 years old), and daughter Divya (3 years old) between 28-29 April 2012, then died by hanging. Evidence suggests he exposed them to chlo…
10y · Male·Hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…
A 10-year-old boy with severe obstructive sleep apnoea and morbid obesity died from hypoxic brain injury following cardiorespiratory arrest. Despite repeated medical interventions and explicit warnings that his condition…
10y · Male·hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…
AA, a 10-year-old boy with morbid obesity and severe obstructive sleep apnoea, died from hypoxic brain injury after a cardiorespiratory arrest. He had been admitted to hospital in May 2008 with these diagnoses and was pr…
42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…
Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…
61y · Female·Peritonitis due to anastomotic leak at gastrectomy site; pathological obesity as…
A 61-year-old woman with pathological obesity died from peritonitis secondary to anastomotic leak following laparoscopic sleeve gastrectomy. The procedure itself was appropriate for her failed previous lap band surgeries…
65y · Female·Liver failure secondary to paracetamol toxicity
A 65-year-old retired nurse died from paracetamol toxicity and liver failure after taking excessive paracetamol tablets for pain relief following a fractured arm. She presented to hospital on Saturday with a fracture. Cr…
24y · Female·diabetic ketoacidosis in the setting of diabetes mellitus
Kylie Anne Lightfoot, a 24-year-old woman with type 1 diabetes, died from diabetic ketoacidosis. She presented to Dr S.'s practice on 4 May 2007 with abdominal pain, having not checked her blood sugar or taken insulin th…
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