98 results
36y · Female·Stab wound to the right chest
Amanda Jane Harris, 36, was fatally stabbed by her intimate partner Daniel Eckersley on 7 July 2018 in Cranbourne North, Victoria. Eckersley was prescribed high-dose tramadol (700-800mg daily) for chronic pain over 22 mo…
74y · Female·Fractures of the legs, with terminal palliative care, in an elderly lady with mu…
Ms Papanastasiou, a 74-year-old aged care resident confined to a wheelchair, died from bilateral femoral fractures sustained when she fell from her wheelchair during sudden bus braking. The wheelchair was secured using o…
68y · Female·Pulmonary embolism due to deep venous thrombosis secondary to fractured left dis…
Mary Morrow, aged 68, died from pulmonary embolism and deep vein thrombosis following a fractured left ankle sustained in Queensland on 23 June 2021. She received appropriate VTE prophylaxis initially (enoxaparin) but th…
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…
93y · Male·Alzheimer's dementia (as recorded on MCCD); however, the death resulted from a f…
Ronald Reginald Slatter, aged 93, died at Mersey Community Hospital on 22 July 2022, three weeks after sustaining a fractured neck of right femur from a fall on 1 July 2022. While the coroner found no issues with his cli…
74y · Male·Pulmonary thromboembolism secondary to deep vein thrombosis in the setting of re…
A 74-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis following a cervical spinal fracture. He presented to rural ED with mental health concerns, was restrained by security guards after …
17y · Male·Hypoxic ischaemic encephalopathy due to hanging
A 17-year-old male who transitioned from female died by hanging on 21 April 2020, seven days after discharge from psychiatric inpatient care. He had complex medical needs including chronic back pain, spinal fusion, post-…
75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…
Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…
70y · Male·hypovolaemic shock due to the consequences of fractured femur
Thomas Fulcher, a 70-year-old man with intellectual disability and osteoporosis in a group home, fell on 19 January 2018 and sustained a spiral femur fracture with internal bleeding. Care workers failed to seek medical a…
47y · Female·Traumatic closed head injury likely sustained in a fall from standing
TS, a 47-year-old woman with a 18-year history of anorexia nervosa, bulimia, and severe alcoholism, died from a traumatic closed head injury sustained in a fall from standing. At autopsy, blood alcohol concentration was …
20y · Female·multi-organ failure due to polypharmacy overdose
A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where i…
54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…
Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…
52y · Male·Stab injuries to the chest
Mark Edwards, a 52-year-old man, died by suicide via stab injuries to the chest on 11 December 2020. He had suffered a workplace injury in 2007 resulting in amputation of his right leg in 2017, chronic pain, multiple sur…
33y · Male·Fatal cardiac arrhythmia, secondary to acute kidney injury
Joshua Szczudlo, a 33-year-old man with morbid obesity (estimated weight 195kg), underwent shoulder fracture repair surgery on 17 March 2016 at Liverpool Hospital. He died 38 hours post-operatively from a fatal cardiac a…
1y · Female·unrecognised oesophageal intubation
A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of pe…
56y · Male·Complications of atraumatic bilateral femoral fractures (repaired) during a seiz…
Mark O'Brien, a 56-year-old man with Down syndrome and dementia, sustained multiple seizure-related bilateral femoral fractures. A subtle posterior cortical fracture to his left femur, sustained during a seizure on 15 Ju…
36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)
A 36-year-old motor mechanic with chronic pain from a 2014 knee injury died from combined drug toxicity (pregabalin, morphine, amitriptyline). His general practitioner, Dr Schneider, prescribed excessive amounts of multi…
78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…
Barbara Francis, a 78-year-old resident with dementia at Pearl Supported Care in the dementia unit (Dinah), was punched by another resident (Mr A) on 4 September 2018 and fell backward onto her right hip, sustaining an o…
21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg
A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…
63y · Female·Pulmonary thromboembolism
A 63-year-old woman died from pulmonary thromboembolism within 24 hours of bilateral total knee arthroplasty despite aspirin and sequential compression devices. The surgeon assessed her as standard risk and did not presc…
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