30 results
29y · Male·Ketoacidosis as a consequence of diabetes mellitus (Type 1)
Steven Thelander, aged 29, died from ketoacidosis due to poorly controlled Type 1 diabetes while in residential disability support care at Multicap. He had cerebral palsy with severe intellectual impairment and epilepsy …
75y · Female·Infective complications of a left hand injury with diabetic ketoacidosis
A 75-year-old woman died from infective complications of a left hand wound sustained in a fall from a ladder in November 2023, complicated by undiagnosed diabetic ketoacidosis. Despite family encouragement to seek medica…
58y · Female·Complications of poorly controlled type 2 diabetes
Ms Kathleen Earl, aged 58, died from complications of poorly controlled type 2 diabetes in June 2022. She had an intellectual disability and received support from IHCS (Individual Support Worker) since 2005. Critical def…
68y · Male·Cerebrovascular disease
John Raymond Ainsworth, a 68-year-old prisoner, died of cerebrovascular disease following a severe stroke on 25 November 2020. He had poorly controlled Type II diabetes, hypertension, and high cholesterol. Prior to his a…
44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…
Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…
16y · Male·Hypoxic/ischaemic encephalopathy in the context of diabetic ketoacidosis
A 16-year-old with Type 1 Diabetes died from diabetic ketoacidosis (DKA) precipitated by acute gastroenteritis acquired while on a school trip to Vietnam. Despite reporting vomiting at 8am on 26 September 2019, Lachlan w…
74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …
William Searle, a 74-year-old prisoner, died from aspiration of gastric contents following a Whipple procedure for recurrent ampullary adenoma. The clinical lessons involve recognition of gastroparesis risk in high-risk …
3y · Male·Hypoxic ischaemic encephalopathy complicating hypoglycaemia with shock and statu…
A 3-year-old boy with septo-optic dysplasia and panhypopituitarism died from hypoxic ischaemic encephalopathy secondary to adrenal crisis and hypoglycaemic shock. He was in state care and had an emergency management plan…
74y · Female·Diabetic ketoacidosis
A 74-year-old woman with Type 1 diabetes died from diabetic ketoacidosis (DKA) in an aged care facility. Between 7-10 December 2016, her blood glucose levels remained persistently elevated (>33 mmol/L) despite escalating…
76y · Male·ischaemic heart disease following hyperglycaemic hyperosmolar syndrome (HHS) due…
Wayne Douglas Tedmanson, aged 76, died from ischaemic heart disease following hyperglycaemic hyperosmolar syndrome (HHS), a complication of type 2 diabetes mellitus. Clinical lessons include recognising HHS presentations…
37y · Male·Unascertained
Kenneth Klees, aged 37, disappeared on 1 February 2021 and was found deceased on Mollymook beach on 26 February 2021. He had a history of depression, anxiety, poorly controlled type 2 diabetes, and obsessive-compulsive d…
57y · Male·Consequences of multiple injuries (from fall from elevated walkway)
Mladen Jovanoski, a 57-year-old remand prisoner, died from head injuries sustained after falling from a prison walkway on 11 April 2018. He had suspected metastatic thyroid cancer requiring urgent biopsy at a tertiary ho…
34y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian), in circums…
Melissa Gaultier, 34 years old, was discharged from Latrobe Regional Hospital's psychiatric ward (Flynn Unit) less than 24 hours after admission on 13 April 2017, despite comprehensive warnings from Monash Health that sh…
61y · Male·metastatic oesophageal neuroendocrine carcinoma
Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attribut…
31y · Male·Hypoxic brain injury caused by the exogenous administration of insulin, resultin…
Jesse Drabsch, 31, died from hypoglycaemia after self-injecting insulin in a gym bathroom. A competitive bodybuilder using performance and image enhancing drugs (PIEDs), Jesse entered the bathroom at 5:30pm on 16 Novembe…
Female·Hanging
This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral…
61y · Female·multi organ failure due to abdominal sepsis
Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery requ…
29y · Male·cardiac arrhythmia
David Dungay, a 29-year-old Aboriginal man with chronic schizophrenia, type 1 diabetes, and obesity, died on 29 December 2015 in Long Bay Hospital's Mental Health Unit while in custody. The immediate trigger was his refu…
33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…
Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraem…
31y · Female·incised wounds to the neck and arms
A 31-year-old illustrator with a recent onset of acute depression and suicidal ideation attended Fremantle Hospital ED via ambulance after GP referral on 12 May 2014. She had made a suicide attempt at a beach two days ea…
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