240 results
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …
An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …
84y · Male·The available evidence does not allow for any finding to be made as to the cause…
An 84-year-old man with Alzheimer's dementia and a history of wandering left his home on 15 September 2017 and was never found alive. The coroner determined he is deceased, likely died within days of going missing in bus…
Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…
Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed bread dipped in Milo by an inexperienced AIN without adequate supervisio…
84y · Male·Complications of fracture left humerus neck due to fall due to hyperactive delir…
An 84-year-old man with Alzheimer's disease and dementia-related behaviours developed a urinary tract infection causing acute delirium, atrial fibrillation, and multiple falls. After presenting to the emergency departmen…
88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…
An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatra…
45y · Male·Environmental exposure and dehydration
A 45-year-old Aboriginal man with severe cognitive impairment (6.5-year-old equivalent English comprehension), traumatic brain injury, epilepsy and multiple medical conditions died from environmental exposure and dehydra…
39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…
Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…
Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…
Two Aboriginal brothers with chronic alcohol use disorder and cognitive impairment died in July and September 2023 in Alice Springs Hospital. Both had adult guardianship orders, NDIS packages, and aged care assessments r…
47y · Male·unascertained
Eric Donald Brandrick, a 47-year-old man with significant disability from a right thalamic intracerebral haemorrhage stroke in September 1988, was last confirmed alive on 31 December 1989 at Royal Perth Hospital Emergenc…
65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …
A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…
90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …
A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …
86y · Female·Hypostatic pneumonia due to the consequences of a right pubic rami fracture and …
An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…
74y · Male·Sepsis secondary to infected pressure wounds (necrotising fasciitis) in a man wi…
A 74-year-old man with multiple comorbidities (diabetes, obesity, respiratory failure, mental health conditions) died from sepsis secondary to necrotising fasciitis of pressure wounds developed while in aged care. Key cl…
89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…
An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…
54y · Male·Complications of pelvic and spinal fractures sustained in a fall in man with Dow…
Andrew William Barr, a 54-year-old man with Down syndrome and Alzheimer's dementia, died from complications of pelvic and spinal fractures sustained in a fall. Following his mother's death in January 2021 and his Februar…
86y · Male·Complications of blunt force trauma in a man with cardiac amyloidosis and athero…
An 86-year-old man with dementia, cardiac amyloidosis and atherosclerotic cardiovascular disease died from complications of blunt force trauma sustained in an assault by his adult son. The deceased had been diagnosed wit…
89y · Female·Acute upper airway obstruction by food bolus
An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significant discrepancies between reported actions and actua…
79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…
A 79-year-old woman with severe COPD and heart failure presented with two weeks of nausea and vomiting. She was diagnosed with left ventricular failure (EF 33%) on day 1 of admission. Two cardiologists had key roles: Dr …
87y · Female·Terminal exacerbation of chronic obstructive pulmonary disease; antecedent cause…
Maureen 'Kitty' McDonald, 87, died from terminal exacerbation of COPD with an antecedent sacral pressure wound infection. She was admitted to residential aged care in October 2020 with a stage-two sacral pressure injury …
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