28 results
45y · Female·Complications of sepsis secondary to sacral pressure wound in a woman with genet…
Kristy Ann Mitchener, a 45-year-old woman with severe intellectual disability, genetic developmental and epileptic encephalopathy, and oesophageal dysmotility, died from sepsis secondary to a sacral pressure ulcer despit…
78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…
78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…
76y · Female·multiple organ failure due to abdominal wall cellulitis (surgically treated)
Mrs Crowther, a 76-year-old obese woman with multiple comorbidities in residential aged care, died from multiple organ failure secondary to abdominal wall cellulitis. A critical care failure occurred when an old dressing…
11y · Male·Sepsis
An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…
41y · Male·complications in association with effects of fire, with terminal palliative care
Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat f…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…
40y · Male·Full thickness burns to body in the setting of self-immolation
A 40-year-old Tamil asylum seeker died from full thickness burns sustained during self-immolation on 20 August 2021. The death occurred three days after Victoria Police attended a family violence incident where KK assaul…
31y · Male·Burns
31-year-old George Grimes with longstanding schizophrenia was found threatening self-immolation after consuming alcohol and missing antipsychotic medication. Despite police de-escalation attempts, he doused himself with …
0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…
A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…
24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns
Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement.…
Female·Burns due to gas explosion due to motor vehicle collision with building
A 60-year-old man with a long-standing history of seizures experienced an epileptic seizure while driving and lost control of his vehicle. It collided with an LPG gas cylinder outside a café, triggering an explosion that…
5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …
A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…
60y · Male·burn wounds and the consequences thereof
CD, a 60-year-old man with long-standing psychiatric history (schizophrenia/schizoaffective disorder) and alcohol use disorder, set his house alight on 19 September 2017 after becoming acutely unwell with paranoid ideati…
87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…
Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (h…
18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…
An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…
48y · Female·Combined toxic effect of prescription and non-prescription medications including…
Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…
53y · Male·Complications of burns sustained in a blast
A 53-year-old qualified boiler maker died from complications of severe burns sustained in a gas explosion. While attempting to remove a refrigeration compressor from a hotel cellar with an unqualified colleague, they cut…
9y · Female·complications of thermal injury
A 9-year-old child died from severe thermal injuries sustained in a house fire. The property had non-functional smoke alarms that the property management company knew about but failed to remedy or report to the landlord.…
45y · Female·multiple organ failure following thermal injuries (severe burns)
Wendy Bearfoot, a 45-year-old DEC (Department of Environment and Conservation) employee, died from multiple organ failure following severe thermal burns (80% of body) sustained in a bushfire burnover on 12 October 2012. …
75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …
A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…
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