196 results
89y · Female·Ischaemic heart disease in a woman with a history of recent assault
Mrs Anderina Sanderson, 89, died from ischaemic heart disease four days after being assaulted by a male resident with dementia in an aged care facility. The forensic pathologist concluded the assault accelerated her decl…
73y · Female·Bacterial endocarditis organism arising from a staphylococcal infection that ent…
Mary Roberts, aged 73, received a 5-year custodial sentence in September 2004. She had complex medical needs: dementia from previous strokes, diabetes requiring insulin monitoring, and Warfarin use. Justice Health provid…
64y · Male·Large pulmonary embolus (origin undetermined)
Paul Brauer, 64, died of pulmonary embolus at Leeton District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. The coroner ident…
78y · Female·Aspiration pneumonia, epistaxis, and trauma to the face
Joan Hendrickson, a 78-year-old with vascular dementia, was assaulted by a co-resident at an aged care facility in April 2006, sustaining facial trauma and epistaxis. She died from aspiration pneumonia 10 days later. The…
85y · Female·Complications of subdural haematoma (evacuated), secondary to fall, contributed …
Patricia Cook, 85, died from complications of a subdural haematoma following a fall at a supported residential service (SRS) while on warfarin for atrial fibrillation. She fell on 30 September 2007, striking her head. Pe…
79y · Female·Sepsis due to urinary tract infection with Group B streptococci
A 79-year-old nursing home resident died of sepsis from urinary tract infection with Group B streptococci after waiting 6 hours in the Emergency Department without being seen by a doctor. She arrived at 8pm with normal v…
80y · Female·Acute upper airway obstruction secondary to aspiration of food bolus
Beatrice Ivy Brown, aged 80, died at an aged care facility from acute upper airway obstruction and aspiration of a food bolus following a choking episode. Clinical lessons include: (1) documentation of prior choking epis…
71y · Male·Positional asphyxia
A 71-year-old man with severe dementia died from positional asphyxia when his neck became wedged in a gate at an aged care facility. He had demonstrated multiple escape attempts within days of admission, with staff docum…
45y · Male·choking on food
Richard Mann, a 45-year-old man with intellectual disability and psychiatric illness residing in an institutional setting (Strathmont Centre infirmary), died from choking on food. Critical failures in observation and mon…
81y · Female·aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphy…
Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive heart failure. A critical ambulance transfer delay …
26y · Female·multiple injuries sustained as a result of being struck by a motor vehicle on th…
A 26-year-old woman with schizo-affective disorder, detained under the Mental Health Act, absconded from a psychiatric hospital and was fatally struck by a vehicle on a freeway. Clinical concerns include: (1) inadequate …
Eva Arany: gunshot wound to the neck; Jeno Arany: traumatic brain damage complic…
An elderly man with severe depression, suicidal ideation, and ongoing psychiatric risk was hospitalised twice in 2000 and discharged on antidepressant medication. Despite staff identifying he owned seven firearms and pos…
69y · Female·Respiratory obstruction by aspirated food (Brussels sprout, chicken and carrots)…
Helena Czekajlo, aged 69, died from respiratory obstruction by aspirated food (Brussels sprout) at a nursing home. She had dementia and schizophrenia with a documented obsession about food and tendency to eat hurriedly. …
73y · Male·dehydration and hyperthermia
A 73-year-old man with mild dementia resident in aged care wandered from the facility on a hot day (31°C+) while taking three medications with anticholinergic properties: pericyazine, haloperidol, and oxybutynin. These d…
78y · Male·suppurative bronchitis complicating chronic obstructive airways disease (emphyse…
A 78-year-old man died of suppurative bronchitis complicating end-stage emphysema at a supported residential facility. Key clinical concerns include: (1) the general practitioner's reliance on unvetted aged care staff to…
85y · Female·Sepsis relating to an infected right shoulder wound (including MRSA)
Ellen Plymin, aged 85, sustained a fractured humerus in a fall and underwent surgical fixation at Western Hospital on 10 May 2007. She returned to Westgate Aged Care Facility post-operatively on 14 May. By 28 May, wound …
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