190 results
58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humeru…
Wayne Anthony Lowe, aged 58, died of multiorgan failure due to sepsis following repeated humeral fractures sustained in falls. He was admitted with a right proximal humeral fracture from an intoxicated fall, discharged a…
41y · Male·Septicaemia secondary to chronic peptic ulcer disease
Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer history diagnosed in November 2020 and sho…
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 …
32y · Male·ligature compression of the neck (hanging) in a man with methadone and methylamp…
Kingsley Garlett, aged 32, died by hanging in a maximum security prison cell on 31 July 2022. The evidence indicates his death was an impulsive response to relationship conflict with his partner revealed through prison p…
31y · Female·organ failure due to anorexia nervosa
Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…
92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…
A 92-year-old man with complex cardiac history was admitted to Royal Hobart Hospital with chest pain and atrial fibrillation. He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, …
74y · Male·small intestinal ischaemia caused by aortic atherosclerosis
A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clea…
75y · Male·End stage myelodysplastic syndrome and end stage renal failure on a background o…
A 75-year-old man died in prison custody from end-stage myelodysplastic syndrome and renal failure on a background of ischaemic heart disease, hypertension, valvular disease, and metastatic prostate cancer. He was admitt…
70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide card…
A 70-year-old woman with complex cardiac history including heart failure, paroxysmal atrial fibrillation, and coronary atherosclerosis presented with urinary tract infection and atrial fibrillation on Christmas Day 2021.…
62y · Male·Metastatic small cell lung carcinoma (palliated)
Mr N, a 62-year-old man in custody, died from metastatic small cell lung carcinoma with palliation. He presented with abdominal pain in late May 2022, and was referred for urgent ultrasound and blood tests on 15 June 202…
76y · Male·metastatic prostate cancer with terminal palliative care
Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including r…
81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…
An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 retention require explicit ident…
35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…
35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues an…
22y · Unknown·sudden death associated with volatile substance inhalation (butane and propane)
A 22-year-old Yolngu person with a well-documented history of volatile substance abuse (VSA) and mental illness was involuntarily admitted to Royal Darwin Hospital for acute psychosis. Due to COVID-19 bed-block, they wer…
27y · Male·unascertained
Neil Lindsay Kobelt, a 27-year-old man with diagnosed schizophrenia, disappeared from Kalgoorlie, Western Australia in February 1982, shortly after discharge from hospital for acute psychiatric crisis. He had relocated t…
76y · Male·pulmonary thromboembolism in the setting of deep vein thrombosis
A 76-year-old man with a history of unprovoked DVT/PE on lifelong warfarin was admitted with COVID-19 and developed a bleeding duodenal ulcer requiring endoscopic treatment. Warfarin was ceased to prevent further bleedin…
48y · Male·Complications of infective exacerbation of bronchiectasis with cor pulmonale
A 48-year-old man with a significant history of bronchiectasis died in police custody from infective exacerbation of bronchiectasis with cor pulmonale. The inquest examined whether police took appropriate steps to obtain…
46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…
Samuel Edward Ashby, a 46-year-old prisoner with treatment-resistant schizophrenia, died from aspiration pneumonia complicated by clozapine effect. Key clinical lessons: (1) smoking cessation dramatically increases cloza…
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
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