246 results
87y · Male·Strangulated small bowel due to adhesions from previous abdominal surgery
An 87-year-old man with diabetes, hypertension and dementia was admitted with presumed UTI and dehydration. Within 24 hours, nursing staff observed a distended abdomen and bile-stained vomiting—clinical signs of bowel ob…
51y · Male·undetermined natural causes
Chris Prasad, a 51-year-old involuntary psychiatric inpatient with schizoaffective disorder, diabetes type 2, hypertension, and obesity (BMI 30.8), was granted day leave on 17 January 2013 during extreme heat (38°C) at C…
84y · Female·Myocardial infarction
Shirley McGuane, 84, died from myocardial infarction following elective proctocolectomy. Post-operative care was deficient: chest pain on day 2 post-op with ECG showing atrial fibrillation and new right bundle-branch blo…
99y · Male·Pneumonia
A 99-year-old man with cognitive decline sustained a hip fracture from a fall and subsequently underwent surgery with informed consent. He suffered cardiopulmonary arrest post-operatively and was resuscitated despite the…
44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)
Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…
32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin
A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…
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…
59y · Male·Cardiac arrest caused by Ischaemic Heart Disease
Angus Dixon, a 59-year-old Aboriginal man with ischaemic heart disease, diabetes, and a history of paranoid psychosis, died from acute myocardial infarction while an involuntary mental health patient at Alice Springs Hos…
Female·Multiple injuries
Yvonne Henderson was a middle-aged woman with chronic delusional disorder who died in a motor vehicle collision on 6 December 2010 while on approved leave from psychiatric hospitalisation. She was an involuntary patient …
58y · Female·Multiple injuries sustained in collision with train (pedestrian)
Elaine Sykes, aged 58, was admitted to Dandenong Hospital with acute renal failure and severe mental health deterioration. After 47 days at Acacia Mental Health Unit, she demonstrated substantial improvement and was disc…
80y · Female·subdural haematoma due to closed head injury sustained in a fall from bed in hos…
An 80-year-old woman with chronic heart failure admitted to hospital fell from bed and hit her head. Although nursing staff were concerned about a possible head injury, the House Medical Officer incorrectly concluded no …
18y · Male·Aspiration pneumonia in a setting of acquired brain injury from non-accidental h…
Jay Dion Sykes, aged 18, died from aspiration pneumonia in the setting of acquired brain injury sustained non-accidentally as an infant. He had severe cerebral palsy, tetraparesis, aphasia, visual impairment, intellectua…
52y · Female·intracerebral haemorrhage in a lady with underlying cerebrovascular disease and …
A 52-year-old woman underwent right carotid endarterectomy for high-grade stenosis. Post-operatively she developed escalating blood pressure readings (160–220 mmHg), headaches, nausea, agitation, and abnormal behaviour o…
40y · Male·Aspiration pneumonia
Jeffrey McCarty, a 40-year-old man with cerebral palsy, severe intellectual disability, dysphagia and recurrent aspiration pneumonia, died from aspiration pneumonia after being placed on a palliative pathway. The coroner…
56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…
60y · Female·hanging
Margaret McCall, a 60-year-old woman with chronic regional pain syndrome and longstanding anxiety and depression, died by hanging. She received multiple ketamine infusions for pain management, with cessation of fentanyl …
90y · Female·Infected sacral ulcer and fluid imbalances in the context of dementia
A 90-year-old woman with dementia, admitted to aged care in September 2012, developed a large necrotic sacral pressure ulcer despite nursing interventions. She was markedly dehydrated and malnourished, repeatedly refusin…
33y · Male·Multiple injuries sustained from falling from height (fifth-floor window ledge) …
AB, a 33-year-old male, died on 20 April 2013 after falling from the fifth-floor window ledge of Liverpool Hospital while under police negotiation. He had been transferred from prison to immigration detention on 9 April …
21y · Male·Sepsis caused by Leptospirosis (Graeme Gulliver); Group A streptococcal meningit…
Three young patients died from severe bacterial infections at rural Queensland hospitals (Mossman and Atherton). All three received delayed diagnoses and treatment. The first patient (21-year-old with leptospirosis) pres…
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