190 results
49y · Male·Complications of a right superficial femoral artery injury (operated) following …
A 49-year-old man died from complications of a right superficial femoral artery injury sustained when he was struck by a circular saw at a landscaping worksite. Despite receiving immediate first aid, emergency transport …
43y · Female·choking on a food bolus
Joanne Callahan, a 43-year-old woman with intellectual disability and autism, died from choking on a food bolus while attending a disability day program. Critical failures in communication between her residential care pr…
25y · Male·Hypoxic ischaemic brain injury due to hanging
Dylan Charlton-Smith, aged 25, died by hanging while in custody at Fulham Correctional Facility. A stressful visit from his partner preceded his death by approximately 50 minutes. A correctional officer identified distre…
36y · Male·hanging
A 36-year-old man died by hanging on 10 July 2018 after leaving his home in Blacktown, NSW. His partner called Triple Zero after 30 minutes, reporting concern for his welfare and that he was acting strangely, restless, a…
39y · Male·Cardiac arrest in a person with pre-existing severe ischaemic heart disease who …
A 39-year-old First Nations man with severe ischaemic heart disease died following police restraint and ambulance care during an emergency examination authority detention. He had sniffed petrol and threatened self-harm; …
50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…
A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleedin…
48y · Male·Ischaemic heart disease complicating restraint of an acutely agitated male
Daniel Richards, 48, died from ischaemic heart disease precipitated by restraint during a mental health assessment at home. He had underlying significant coronary artery disease with left ventricular hypertrophy and old …
3y · Female·complications of Influenza B viral infection
Three-year-old Caitlin Cruz presented to a medical centre unwell and collapsed, requiring resuscitation. She was transferred by ambulance to Children's Hospital at Westmead but critical information about her collapse and…
31y · Male·Hypoxic brain injury caused by the exogenous administration of insulin, resultin…
Jesse Drabsch, 31, died from hypoglycaemia after self-injecting insulin in a gym bathroom. A competitive bodybuilder using performance and image enhancing drugs (PIEDs), Jesse entered the bathroom at 5:30pm on 16 Novembe…
Unknown·Mr Christensen: stab wound to the chest. Mr Davy: blood loss caused by stab woun…
Two men died following stab wounds sustained while forcing entry to a dwelling in the early hours of 1 October 2018. The deceased had been misled about the circumstances of an injured woman they believed needed urgent as…
42y · Female·Traumatic right subdural haematoma
A 42-year-old woman died from a traumatic right subdural haematoma sustained on 22 January 2015. She was found unresponsive at home with severe head and facial injuries after falls. Critical delays in medical assessment …
3y · Female·Hypoxic-ischaemic encephalopathy due to chorioamnionitis due to Gardnerella Vagi…
Zamia Ely-Smith died at 3 days of age from hypoxic-ischaemic encephalopathy due to chorioamnionitis following home birth at term. Clinical lessons include: (1) decreased fetal movements at 39+ weeks gestation and hospita…
31y · Male·Gunshot wounds to the neck and chest
Liam Scorsese, 31, died from gunshot wounds inflicted by police during a confrontation at his estranged partner's parents' home in Queensland. He had a history of violence, substance abuse (methamphetamine, cocaine), and…
44y · Female·haemoperitoneum due to ruptured splenic subcapsular haematoma in the setting of …
Kylie Cay, a 44-year-old woman, was brutally assaulted by her partner Justin Turner on 18 June 2016, sustaining rib fractures and other injuries. She was discharged from hospital on 20 June after imaging did not reveal a…
30y · Male·Malignant ventricular arrhythmia without myocardial infarction, precipitated by …
Jack Kokaua, a 30-year-old with schizophrenia and coronary artery disease, died from malignant ventricular arrhythmia during a police encounter after absconding from hospital. Contributing factors included positional asp…
80y · Female·acute subdural haematoma following a fall while on warfarin for atrial fibrillat…
Mrs Bowerman, aged 80, fell at home on warfarin anticoagulation and sustained a minor head injury with no initial neurological signs. Paramedic Turnbull assessed her as requiring no transport (TNR), despite her anticoagu…
49y · Male·Stab wound to the chest
A 49-year-old man with anxiety and depression died from a self-inflicted stab wound to the chest sustained during police response to a domestic violence call. He had brought tools and weapons to his ex-partner's home. Wh…
39y · Male·Choking on a food bolus
Mark Capovilla, a 39-year-old man with severe intellectual disability, epilepsy, and dysphagia, died from choking on food at his day program. He had a documented choking risk but lacked a current mealtime support plan at…
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…
76y · Female·Ludwig's angina
A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognis…
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