1,111 results
47y · Female·head injury
Sohaila Mohammadi (47) was killed in a motor vehicle collision caused by driver Tristan Mourant, who had bilateral retinal dystrophy and was advised by three medical professionals not to drive. However, none of the docto…
88y · Female·Cardiac failure secondary to pacemaker failure and pacemaker battery exhaustion
This case involves an 88-year-old woman with a pacemaker who became lost to follow-up after her last clinic visit in May 2019, when no follow-up appointment was arranged. Without systematic tracking between the specialis…
23y · Male·complications of bowel obstruction by adhesions
A 23-year-old man in lawful custody at Parklea Correctional Centre presented on 7 January 2022 with severe chest pain, abdominal pain, vomiting, and dehydration, with a significant history of previous abdominal surgery a…
70y · Male·metastatic gastric adenocarcinoma
A 70-year-old man with prior bladder cancer was undergoing routine CT surveillance. Stomach cancer signs were clearly visible on February 2017 and February 2018 CT scans but failed to be detected by consulting radiologis…
94y · Female·Drug toxicity (baclofen, gabapentin, oxycodone, pregabalin, zolpidem)
A 94-year-old residential aged-care resident died from drug toxicity after receiving another resident's medications. An agency nurse, unfamiliar with the patient and interrupted during medication preparation, failed to p…
Male·ligature compression of the neck (hanging)
Kyen Tollett, remanded at Casuarina Prison, died by hanging on 10 October 2024. He had a well-documented history of relationship-triggered suicidality and received high-quality psychiatric care and counselling throughout…
61y · Male·bronchopneumonia complicating cerebrovascular accident due to cardioembolism on …
A 61-year-old man with a mechanical aortic valve underwent colonoscopy requiring temporary warfarin cessation. Following the procedure, he was discharged with a plan to recommence warfarin but without clear postoperative…
61y · Male·Exsanguination from sharp force injuries to both arms, dissecting the veins of t…
CG, aged 61, died in Parklea Correctional Centre on 18 May 2024 from hemorrhage due to self-inflicted sharp force injuries. The coroner found multiple clinical and system failures contributed substantially to the death. …
72y · Female·Combined drug toxicity (tapentadol, fluoxetine)
Linda Joy Bridle, 72, died from combined drug toxicity (tapentadol and fluoxetine) with a contributing subdural haemorrhage. She had multiple chronic conditions including heart failure and chronic pain, managed through c…
67y · Male·Multi-organ failure secondary to acute myocardial infarction secondary to in-ste…
Christopher Doughty, 67, was admitted to Hervey Bay Hospital on 17 September 2021 with a life-threatening gastrointestinal bleed two months after receiving coronary stents. The bleed was likely caused by dual antiplatele…
<1y · Male·traumatic head injury due to instrumental vaginal delivery of a term infant
Baby H died on 24 March 2019, one day after birth, from traumatic head injuries sustained during an instrumental vaginal delivery using Neville Barnes forceps on a baby in occipito-posterior position. Critical clinical l…
Male·phosphine toxicity in a man with atherosclerotic heart disease
Robert Lavars died on 6 September 2022 after deliberately ingesting aluminium phosphide tablets while under police arrest at his home in Shoalwater. He had serious health conditions including strokes, heart disease, and …
[77, 80, 55]y · Unknown·Multiple injuries from motor vehicle collision
A motor vehicle collision on the Princes Highway near Suttontown killed three adults when a 16-year-old driver with significant neurological conditions momentarily lost concentration while ascending a hill. The driver ha…
24y · Female·Mixed drug toxicity
Sheridan Burnell, 24, died from mixed drug toxicity following an intentional overdose of prescription medications (lamotrigine and quetiapine) on 2 January 2021. Her mental health care was reasonable and appropriate. The…
25y · Female·Mixed drug consumption (pregabalin, oxycodone, desmethylvenlafaxine, aripiprazol…
Kaylah Veronica Sarah Woollard, age 25, died from mixed drug toxicity in the context of significant natural disease. She had WHO Class III obesity (BMI 94.5), cardiac hypertrophy, and mental health conditions (depression…
17y · Male·Suicide by self-inflicted hanging
RL was a 17-year-old Alice Springs teenager who died by suicide while under Northern Territory mental health services' care. Critical clinical lessons emerged: failure to inform his mother about mental health deteriorati…
52y · Male·Gunshot wound to the chest
Steven Richard Angus, a 52-year-old veteran with severe alcohol use disorder, major depressive disorder, and generalised anxiety disorder, died from a gunshot wound inflicted by Queensland Police during a welfare check o…
86y · Male·Multiorgan failure due to neurological failure due to Alzheimer's dementia
An 86-year-old man with advanced Alzheimer's dementia developed multiple pressure injuries while residing in aged care. A Stage 1 sacral pressure wound rapidly deteriorated to Stage 4 over two weeks despite appropriate a…
82y · Male·Multiorgan failure due to neurological failure due to Parkinson's disease with a…
Mr M, aged 82, with advanced Parkinson's disease and dementia, developed severe pressure injuries while in residential aged care. A significant sacral pressure wound went undetected until mid-December 2023 and rapidly de…
87y · Male·Multiorgan failure due to sepsis due to skin failure, underlying vascular dement…
An 87-year-old man with vascular dementia and stroke-related quadriplegia developed a sacral pressure injury in a residential aged care facility in December 2023. Despite care interventions, the wound rapidly deteriorate…
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