72 results
56y · Male·Complications of advanced metastatic sigmoid adenocarcinoma in an adult man with…
Wayne Harris was a 56-year-old Aboriginal man with advanced metastatic sigmoid adenocarcinoma who died in prison custody from complications of his terminal cancer. He was incarcerated for 11 years for child sex offences.…
69y · Male·advanced cholangiocarcinoma
Mr Lifa Faafete, aged 69, died from advanced cholangiocarcinoma while in remand custody at Metropolitan Special Programs Centre. He was appropriately transferred to Prince of Wales Hospital on 22 March 2025 for symptom m…
53y · Male·disseminated malignant melanoma
A 53-year-old man died of disseminated malignant melanoma while incarcerated at Yatala Labour Prison. Initial excision of a large arm mole in November 2019 revealed Stage III melanoma. A January 2020 multi-disciplinary t…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
66y · Male·infectious complications of plasmablastic myeloma
Mati Tamwoy, a 66-year-old Aboriginal man, died in ICU from infectious complications of plasmablastic myeloma after 661 days on remand. He received excellent oncological care including chemotherapy and radiotherapy. Howe…
82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis
An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
81y · Male·Carcinoid tumour (metastasis) / metastatic cancer
Donald Richard Gunthorpe, an 81-year-old man with metastatic rectal carcinoma, was appropriately transitioned to end-of-life (palliative) care at a residential aged care facility after hospitalisation for abdominal pain.…
82y · Male·Self-inflicted partial contact shotgun wound of the head
An 82-year-old man with recently diagnosed myeloma died by self-inflicted shotgun wound. He had undergone intensive chemotherapy causing significant deterioration in physical health, mental state, and independence. Six w…
68y · Male·Unknown; likely suicide by unknown means
Michael Molony, a 68-year-old man living alone in Yarraville, disappeared on 3 January 2020 after reporting health concerns to family. He had a history of skin cancer treated in 2015-2017 but was not receiving ongoing me…
71y · Female·complications of metastatic endometrial carcinoma, treated palliatively
Corazon Contreras Keeley, a 71-year-old woman with postmenopausal bleeding, was investigated for possible endometrial cancer. Dr Venkata Kasina performed a hysteroscopy with dilation and curettage (HDC) on 29 November 20…
76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…
A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2…
73y · Male·Complications of metastatic neuroendocrine lung carcinoma
John O'Donnell, aged 73, died in custody from complications of metastatic neuroendocrine lung cancer while hospitalised at Westmead Hospital. The coroner identified two systemic issues during his brief incarceration at S…
76y · Female·Effects of fire in a woman with head and neck injuries
Mrs Emma Weidemann, aged 76, died from burns sustained in a fire deliberately set by her husband Rudolf at their home on 11 December 2019. Rudolf had recently been diagnosed with terminal cancer, experienced cognitive de…
25y · Female·multiple injuries
A 25-year-old woman with newly diagnosed metastatic gastro-oesophageal cancer and depression died by suicide on hospital grounds. She was admitted on 30 January 2021 after imaging showed cancer progression. Her sister di…
87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …
Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…
84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …
An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…
24y · Male·Injuries sustained in fall from height
SJ, a 24-year-old man with recently diagnosed Stage 4B non-Hodgkin lymphoma and pre-existing depression managed by Orygen Youth Health, died by suicide on 22 September 2016 by jumping from the seventh-floor rooftop garde…
80y · Female·Anaphylaxis complicating chemotherapy for the treatment of metastatic fallopian …
Ms Heather Jean Lucas, 80-year-old woman with metastatic fallopian tube cancer, died from anaphylaxis during her third carboplatin chemotherapy infusion. She had experienced a documented Grade 2 hypersensitivity reaction…
71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)
Leslie Shortte, a 71-year-old life prisoner, died from metastatic squamous cell carcinoma with complications. Critical failures in his prison medical care included: failure to complete annual health assessments after 201…
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