133 results
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
86y · Female·Pulmonary thromboembolism in the setting of deep leg vein thrombosis, secondary …
Barbara Deal, 86, died from pulmonary embolism secondary to deep vein thrombosis 17 days after lumbar spinal fusion surgery. Critical failures included: no repeat VTE risk assessments despite policy requirements; inconsi…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
0y · Unknown·unascertained
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…
82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis
An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
71y · Male·RACF acquired pneumonia and Alzheimer dementia
Ross Stuart Blades, a 71-year-old man with Alzheimer dementia and squamous cell carcinoma, died of RACF-acquired pneumonia while residing in an aged care facility. He was found deceased on the floor beside his bed. The c…
47y · Male·Sudden cardiac death in association with COVID-19 infection
Alen Imbrisak, a 47-year-old man incarcerated at Junee Correctional Centre, died on 26 January 2022 from sudden cardiac death in association with COVID-19 infection. He tested positive on 25 January 2022 during a centre-…
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…
9y · Female·Streptococcus pneumoniae and Candida albicans pneumonia and empyema in a girl wi…
Makayla Lee Wadeson, a 9-year-old autistic girl with ulcerative colitis on immunosuppressive therapy, presented to the emergency department with ear infection symptoms on 29 July 2022. She was triaged Category 4 and disc…
11y · Male·Sepsis
An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…
5y · Male·Septic shock due to Influenza A infection and bacterial co-infection with Staphy…
A 5-year-old boy died from septic shock complicating influenza A with bacterial co-infection (Staphylococcus aureus or Group A Streptococcus). He presented to the ED on 22 May 2022 with fever, abdominal pain, and vomitin…
2y · Female·Complications of bacterial chest infection (Staphylococcus aureus)
A 2-year-old Aboriginal and Torres Strait Islander girl died from complications of bacterial chest infection (Staphylococcus aureus) with concurrent Human metapneumovirus infection, presenting as left empyema and bilater…
0y · Male·unascertained, in an unsafe sleeping environment, on a background of respiratory…
Baby Caleb, aged 2 months, died on 30 November 2018 in an unsafe sleeping environment while his mother co-slept with him on a fold-out sofa in a squalid home. He had a concurrent respiratory tract infection. The coroner …
30y · Female·tricuspid valve bacterial endocarditis
Jennifer Collins, a 30-year-old intravenous methylamphetamine user, died from tricuspid valve bacterial endocarditis on 6 September 2018. She presented to Noarlunga Hospital ED on 20 August 2018 with chest tightness, fev…
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…
26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia
Ashleigh Rebecca Hunter, a previously healthy 26-year-old, died from meningococcal septicaemia (W strain) within 3 hours of arriving at Royal Perth Hospital. She presented with severe generalised pain (10/10), tachycardi…
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
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